Risk of Readmission and the Elderly Patient's Perspective of Return to Everyday Life After Discharge from a Short-Stay Unit at the Emergency Department

Risk of readmission and the elderly patient's perspective of return to everyday life after discharge from a short-stay unit at the Emergency Department

PhD dissertation

Louise Møldrup Nielsen

Health Aarhus University 2018

Risk of readmission and the elderly patient's perspective of return to everyday life after discharge from a short-stay unit at the Emergency Department

PhD dissertation

Louise Møldrup Nielsen

Health Aarhus University Clinical Medicine, Forensic medicine and Odontology

Supervisors Hans Kirkegaard, MD, PhD, Professor (Main supervisor) Research Centre for Emergency Medicine Aarhus University Hospital, Denmark

Lisa Gregersen Østergaard, OT, PhD, Assistant Professor Department of Physiotherapy and Occupational Therapy Aarhus University Hospital, Denmark

Thomas Maribo, PT, PhD, Associate Professor Department of Public Health and DEFACTUM Aarhus University, Denmark

Kirsten Schultz Petersen OT, PhD, Associate Professor Department of Health Science and Technology Aalborg University, Denmark

Evaluation committee Viola Burau, PhD, Associate Professor (Chairman) Department of Public Health, Aarhus University, Denmark

Birgitte Nørgaard RN, PhD, Associate Professor Department of Public Health University of Southern Denmark, Denmark

Susanne Iwarsson OT, PhD, Professor Department of Health Sciences Lund University, Sweden

Preface This PhD project was accomplished during my part-time employment at the Department of Physiotherapy and Occupational therapy, Aarhus University Hospital, Aarhus, Denmark. This work has been made possible because of the advice, help and support from numerous people.

First of all, I would like to express my most grateful thanks to the elderly patients who participated in the studies in this PhD project. You opened your homes and took the time to participate and made this project possible. I sincerely thank my supervisors, Hans Kirkegaard, Thomas Maribo, Lisa G. Østergaard and Kirsten S. Petersen, for your supervision, guidance and encouragement throughout the whole project. I would also like to express my gratitude to the staff members in this project. Thank you for incredible work with the recruitment of participants, carrying out the interventions and the follow-up visits. Thank you to the entire staff at the Emergency Department at Aarhus University Hospital, NBG and thank you to the staff and management of the municipality of Aarhus for participation and cooperation Thank you to the management at the Department of Physiotherapy and Occupational therapy, Aarhus University Hospital: Helle Kruuse-Andersen and Morten Albæk Skrydstrup and to Marianne Høllund, manager of the Department of Occupational Therapy at VIA University College. Thank you for giving me the opportunity to do this study and supporting me. A special thanks to my colleague and fellow PhD student Tove Lise Nielsen for support, friendship and numerous discussions.

A special acknowledgement goes to the funders, the Danish Occupational Therapy Foundation, the Tryg Foundation, the Foundation of Public Health in the Middle and Aase and Ejnar Danielsen’s Foundation, without which this work would not have been possible.

Finally, I want to thank my family and friends for your endless support through the whole project. To Thomas and our wonderful kids, Alberte and Anton, thank you for being there reminding me of what life is all about. Louise M. Nielsen Aarhus, October 2018

Papers: The scientific work presented in this PhD dissertation was performed at the Department of Physiotherapy and Occupational Therapy at Aarhus University Hospital, Aarhus, Denmark, and the Emergency Department at Aarhus University Hospital, Aarhus, Denmark.

The PhD project and dissertation are based on the following three papers:

I. Development of a complex intervention aimed at reducing the risk of readmission of elderly patients discharged from the emergency department using the Intervention Mapping protocol. Published in: BMC Health Services Research 2018;18:588 (1).

II. Effectiveness of the "Elderly Activity Performance Intervention" on elderly patients discharge from a short stay unit at the Emergency Department– A quasi- experimental trial. Published in: Clinical Interventions in Aging 2018;13:737-747 (2).

III. Returning to everyday life after discharge from a short stay unit at the Emergency Department – a qualitative study of elderly patients’ experiences. Submitted to: International Journal of Qualitative Studies in Health & Well-being, June 2018 (in review) (3).

List of abbreviations

ADL: Activities of Daily Living AMPS: Assessment of Motor and Process Skills bADL: basic Activities of Daily Living CCI: Charlson's Comorbidity Index CGA: Comprehensive Geriatric Assessment CI: Confidence Interval CONSORT: Consolidated Standards of Reporting Trials COPM: Canadian Occupational Performance Measure COREQ: Consolidated Criteria for Reporting Qualitative Research EAP intervention: Elderly Activity Performance intervention ED: Emergency Department FIM: Functional Independence Measure GP: General Practitioner ISAR: Identification of Seniors at Risk IADL: Instrumental Activities of Daily Living IQR: Inter Quartile Range HR: Hazard Ratio HRQol: Health-related quality of Life MoHO: Model of Human Occupation NEADL: Nottingham Extended Activities of Daily Living scale OR: Odds Ratio PICO(c): Population Interventions Comparators Outcomes (context) PPI: Patient and public involvement RCT: Randomized Controlled Trial RD: Risk Difference RR: Risk Ratio SD: Standard Deviation TIDieR: The Template for Intervention Description and Replication TUG: Timed Up and Go WHODAS 2.0: World Health Organisation Disability Assessment Schedule 2.0 30s-CST: 30s-Chair Stand Test

Contents English summary ...... 1 Danish summary/Dansk resume ...... 3 1. Introduction ...... 5 2. Background ...... 7 3. Aims and hypotheses ...... 31 4. Methodology and methods ...... 32 Design ...... 32 Theoretical perspectives ...... 34 Study population ...... 35 Methods study Ia: Development and description of the intervention ...... 35 Methods study Ib: Outcome evaluation of the intervention ...... 37 Methods study II: Patients’ perspectives ...... 42 Ethical issues ...... 46 5. Results ...... 47 Results study Ia: Description of the intervention ...... 47 Results study Ib: Outcome evaluation of the intervention ...... 53 Results study II: Patients’perspectives ...... 58 Summary of results ...... 61 6. Discussion ...... 62 Discussion of the main results ...... 62 Methodological considerations ...... 69 7. Conclusion ...... 77 8. Clinical implications and future research ...... 78 9. References ...... 80 10. Papers ...... 92 11. Appendices ...... 140

English summary

Background: Increasing numbers of older people are admitted to emergency departments’ (EDs) short-stay units in Denmark. Elderly patients often present atypical symptoms, comorbidity and limitations in performing activities, complicating care and treatment, and increases their risk of readmission after discharge. Due to the their health conditions’ complexity, elderly patients typically need to receive care and rehabilitation from different healthcare sectors. Therefore, it is important to find a way to meet the rehabilitation needs of elderly patients discharged from a short-stay unit at an ED and provide a well-coordinated and safe transition from the secondary to the primary healthcare sector.

Aim: The present PhD project aims to improve and inform current practices regarding the discharge of elderly patients from a short-stay unit at an ED in order to reduce their risk of readmission. This was done through two studies, reported in three papers.

Methods: Study I comprised two parts. In the first part (Study Ia, Paper I), development of the Elderly Activity Performance-intervention was conducted and described systematically through the Intervention Mapping approach. In the second part (Study Ib, Paper II), an outcome evaluation of the effectiveness of the developed intervention was conducted in a quasi-experimental trial comparing an intervention group (n=144) and a usual practice group (n=231). In Study II (Paper III), qualitative interviews were conducted with 11 elderly patients who received the intervention in study Ib to examine their experiences of being discharge and returning to everyday life after discharge from a short stay unit at an ED.

Results: In Study I, the Elderly Activity Performance intervention was developed to address two risk factors: 1) limitations in performing activities and 2) an incoherent discharge for elderly patients discharged from a short-stay unit at the ED. In total, 375 elderly patients were included in the study to evaluate the effectiveness of the developed intervention. The outcome evaluation revealed that the Elderly Activity Performance intervention was not effective in reducing the risk of readmission compared to usual practice. However, the results revealed that 60% of patients in the intervention group had limitations in performing activities, thus, the need for further rehabilitation was identified. It also revealed that the elderly patients identified as having activity limitations were at higher risk of readmission than patients with no identified limitation. This was supported by results from Study II,

where eleven elderly patients expressed that their everyday lives after discharge were influenced by pain, fatigue and lack of energy, which limited their performance of activities. Speculations concerning their health condition and the future were also present in their everyday lives. The qualitative interviews further revealed that factors such as receiving information, feeling secure and being involved and prepared were considered important by the elderly patients during discharged from a short-stay unit at an ED.

Conclusion: Evaluating the effectiveness of the Elderly Activity Performance intervention revealed no effectiveness in reducing risk of readmission in elderly patients discharged from a short stay unit at the ED. The results, however revealed that elderly patients identified with limitations in performing activities were at higher risk of readmission than patients with no identified limitations. In addition, the PhD project contributed with knowledge concerning how elderly patients experienced being discharged and returning to everyday life after discharge from a short-stay unit at an ED. Receiving information, being prepared and involved and feeling secure about returning home were identified as factors of importance for the elderly patients during discharge. Factors such as limitations in performing activities and speculations concerning health condition and the future were present in the elderly patients’ everyday lives after discharge.

Danish summary/Dansk resume

Baggrund: Et stigende antal ældre bliver indlagt på korttidsobservations- og behandlingsafsnit tilknyttet akutafdelinger i Danmark. Ældre patienter indlægges ofte med atypiske symptomer, komorbiditet og begrænsninger i udførelsen af aktiviteter, hvilket komplicerer pleje og behandling og øger risikoen for genindlæggelse efter udskrivelse. På grund af kompleksiteten i deres helbredstilstand har ældre patienter typisk behov for at modtage pleje og genoptræning fra forskellige sundhedssektorer. Det er således vigtigt at finde en måde at imødekomme genoptræningsbehovet hos ældre patienter, der udskrives fra akutafdeling og at sikre en velkoordineret og sikker overgang mellem den primære og sekundære sundhedssektor.

Formål: Dette Ph.d. projekt har som formål at forbedre og informere nuværende praksis vedrørende udskrivelse af ældre patienter fra akutafdeling med henblik på at reducere de ældres risiko for genindlæggelse. Ph.d. projektet omfattede to studier, der blev afrapporteret i tre artikler.

Metode: Studie I bestod af to dele. Den første del (Studie Ia, artikel I) omfattede udviklingen af interventionen "Ældres Aktivitets Udførelse" som blevet beskrevet systematisk ud fra metoden Intervention Mapping. I anden del (Studie Ib, artikel II) blev effekten af den udviklede intervention evalueret i et kvasi eksperimentelt design ved sammenligning af en interventionsgruppe (n=144) og en sædvanlig praksis gruppe (n=231). I Studie II (artikel III) blev der gennemført kvalitative interviews med elleve ældre patienter der havde modtaget interventionen i Studie Ib. Interviewene blev gennemført for at undersøge de ældres oplevelse af udskrivelsen samt hvordan de oplevede at vende tilbage til hverdagen efter udskrivelse fra akutafdelingen.

Resultater: I Studie I blev interventionen "Ældres Aktivitets Udførelse" udviklet for at adressere to risiko faktorer for genindlæggelse: 1) begrænsninger i udførelsen af aktiviteter og 2) usammenhængende udskrivelse af ældre patienter der udskrives fra korttidsobservations- og behandlingsafsnit tilknyttet akutafdeling. I alt 375 ældre patienter blev inkluderet i studiet for at evaluere effekten af den udviklede intervention. Evalueringen viste, at interventionen ikke signifikant kunne reducerer risikoen for genindlæggelse sammenlignet med sædvanlig praksis. Imidlertid viste resultaterne at 60% af patienterne i

interventionsgruppen havde begrænsninger i udførelsen af aktiviteter og et behov for videre genoptræning. Resultaterne viste desuden at de ældre patienter der blev identificeret med begrænsninger i udførelsen af aktiviteter i højere grad var i risiko for genindlæggelse end de patienter der ikke havde begrænsninger. Det blev understøttet af resultaterne fra studie II hvor elleve ældre patienter udtrykte at deres hverdag efter udskrivelsen var påvirket af smerte, træthed og manglende energi, hvilket begrænsede dem i udførelsen af aktiviteter. Hverdagen var for de ældre patienter også præget af spekulationer omkring deres helbredsstilstand og fremtiden. Resultaterne fra de kvalitative interviews viste ligeledes at faktorer som at modtage information, føle sig tryg, blive involveret og føle sig forberedt var vigtige for de ældre patienter i forbindelse med deres udskrivelse fra en akutafdeling.

Konklusion: Evalueringen af interventionen "Ældres Aktivitets Udførelse" viste at interventionen ikke var effektiv til at reducere risikoen for genindlæggelse for ældre patienter udskrevet fra akutafdeling. Resultaterne viste dog at de patienter der blev identificeret med begrænsninger i udførelsen af aktiviteter var i højere risiko for genindlæggelse end de patienter hvor der ikke blev identificeret begrænsninger. Ph.d. projektet bidrager ligeledes til en forståelse af, hvordan ældre patienter oplever udskrivelsen og det at vende tilbage til en hverdag efter udskrivelse fra akutafdeling. At modtage information, føle sig forberedt og involveret samt føle sig tryg ved at vende hjem blev identificeret som faktorer af betydning for de ældres oplevelse af udskrivelsen. Faktorer som begrænsninger i udførelsen af aktiviteter og spekulationer omkring helbredstilstand og fremtiden var tilstede i de ældres hverdag efter udskrivelsen.

1. Introduction Internationally, as well as in Denmark, the increasing proportion of people above 65 years of age, has been pressuring the healthcare system (4–6). The number of elderly patients admitted to emergency departments (EDs) has been increasing and accounts for up to a quarter of all ED visits (5,7,8). Elderly patients often present atypical symptoms, comorbidity and limitations in performing activities. This complicates treatment, especially at an ED, which is designed to deal with trauma and acute illnesses within a short time frame (6,8). As a result, elderly patients’ serious health needs easily can go unmet, and subsequently, adverse events such as readmission and death after discharge from the ED can occur (7–9). In addition, elderly patients typically receive care and rehabilitation from different providers across multiple healthcare settings due to their health conditions’ complexity. An important challenge is to find a way to identify and meet the rehabilitation needs of elderly patients to be discharged from a short-stay unit at an ED and to provide a well-coordinated discharge and transition from the secondary to the primary healthcare sectors. The aim of the present PhD project is to improve and inform current practices concerning elderly patients’ discharge from a short-stay unit at an ED in order to reduce their risk of readmission.

Definitions This PhD dissertation focusses on two factors associated with the risk of readmission; elderly patients’ performance of activities and incoherent discharge. Some terms used often in this dissertation are clarified below:

Elderly patients: An elderly patient is age 65 or older and is characterised by at least two of the following: severe illness, comorbidity, polypharmacy, limitations in performing activities, poor nutrition, living alone or needing assistance with personal and/or practical tasks (10). In this dissertation, the term is used when such a patient is admitted to a hospital.

Older people: This term is used to describe the population that is age 65 and up generally.

Performing activities: Identifying and addressing limitations in performing activities are key issues addressed in occupational therapy. Performing activities is defined as ”the execution of a task or action by an individual in his or her current environment” (11).

Coherent discharge: A coherent discharge is characterised by health professionals’ collaboration across health care sectors with a high level of coordination, and with a clear distribution of responsibilities supported by consistent information pathways (10). The definition is based on the Danish National Action Plan for the Elderly Medical Patient (10).

2. Background The Danish healthcare system The healthcare system in Denmark operates across three political and administrative levels: the state, regions and municipalities. The system is tax-financed and almost fully free of charge for citizens (12). The regions comprise the system’s secondary sector and are responsible for hospital care, including emergency care and general practitioners’ (GP) healthcare services. The service in this sector primarily aims to prevent and treat diseases and disabilities according to the Danish Health Act (13). The municipalities comprise the primary sector and are primarily responsible for rehabilitation and homecare services for all other citizens in need, including discharged patients (14). One of the goals of providing rehabilitation services is to promote individuals’ ability to care for themselves including to facilitate the performance of activities and improving quality of life (14). The Danish Health Act specifies that rehabilitation begins during a patient’s hospital admission and continues in the primary care sector after discharge (13). Recently, legislative changes to the Danish Health Act specify that the primary sector’s initiation of rehabilitation after discharge must begin within seven days after referral (15). Professionals involved in post-discharge rehabilitation primarily are occupational therapists, physiotherapists and home-care assistants.

In Denmark, political forces aim to improve and strengthening efforts directed towards elderly patients with medical diagnoses in order to optimise coordination between the primary and secondary sectors (10).

Short-stay units in emergency departments: Demand for acute hospital care continues to rise as aging populations grow. One proposed solution to challenges from this demand on the healthcare system is to establish short-stay units in the secondary sector. The term short-stay unit applies to a wide range of hospital units that provide short-term care and treatment for certain patients (16). In Denmark, emergency departments (EDs) are organised with short- stay units in which patients are admitted for observation or brief treatment before they are either discharged to their homes or transferred to other hospital departments. In some countries like Australia, North America and the UK, occupational therapy services have been provided at EDs for over 20 years, while in Denmark, such services are merely

emerging (17–21). The evidence for providing occupational therapy at EDs in Denmark remains limited (20). Occupational therapists’ role at a short-stay unit at the ED emphasises assessment of the patient’s performance of activities, prescribing assistive devices and referring the patient to the services of primary sector service to ensure a safe and coordinated discharge (18–21).

Elderly patients in emergency departments Elderly patients' contact with EDs is high when compared with younger patients' use; this is persistent across countries with different healthcare systems (6,22). In general, elderly patients who attend an ED, are characterised by the following: severe illness, comorbidity, polypharmacy, limitations in performing activities and needing assistance with personal and/or practical tasks (6,10). The complexity that characterises elderly patients' health conditions may be seen as a result of the aging process, that increases their sensitivity to diseases. As a person ages, the immune system weakens and the body becomes more susceptible to a variety of diseases (23). Common health conditions that are presented in elderly patients include cardiopulmonary diseases, neurological conditions, diabetes, cancer, dementia, fractures and depression (8). Atypical presentation of symptoms is frequent in elderly patients, because symptoms vary, and psychological and cognitive domains also are involved (24).

Readmission Readmission is a common and well-known adverse event for elderly patients discharged from an ED (5,25). In Western countries, up to 20% of elderly patients’ admitted to an ED are readmitted within 30 days after discharge (7,24,26). After 26 weeks, more than 40% of discharged elderly patients’ are readmitted (9,27). Readmissions have considerable consequences for both the elderly patient and society in general. For elderly patients, readmission disrupts their routines in everyday life and exposes them to avoidable risks such as hospital-acquired infections and medical complications (7,28). In addition, during hospitalisation elderly patients are more likely to develop a hospitalisation-associated disability between the onset of the illness and discharge to their homes (29,30). From a societal perspective, readmissions are costly and have become a policy priority in efforts to improve healthcare quality (31,32). From an occupational therapy

perspective, two risk factors have been identified as particularly relevant in practice concerning risk of readmission: elderly patients’ limitations in performing activities and an incoherent discharge (18,20).

Limitations in performing activities: Several studies have examined which risk factors predict readmission among elderly patients in general (24,33–35). Limitations in performing activities can be either a pre-existing limitation or a limitation arising from acute illness. In general limitations in performing activities appears as an important predictor of readmission (35–37), as well as other adverse events such as a greater need for home care after discharge (38) and death (39). A systematic review from 2011 concluded that morbidity and limitations in performing activities were the most common risk factors for readmission in elderly patients, whereas age and gender were not associated with readmission (34). For elderly patients with decreased capacity, inactivity during even a short admission is associated significantly with the onset or additional loss of the ability to perform activities (40,41). Limitations in performing activities can also affect elderly patients’ everyday lives after discharge (37). Elderly patients may encounter difficulty maintaining independence and may experience fatigue and decreased physical function including loss of muscle function (42,43). This may hinder the performance of activities and thereby induce a vicious circle, with more inactivity and further dependency as a result (29,44).

Incoherent discharge: Readmissions also may indicate that different healthcare sectors are not working together optimally, or that discharges are not coordinated sufficiently to handle elderly patients’ complex needs (45). Due to the complexity of their health conditions, elderly patients often receive treatment, care and rehabilitation from different sectors of the healthcare system, and the transfer of elderly patients’ rehabilitation from the hospital to primary care may present a challenge (10,37,46). Therefore, effective collaboration between healthcare providers from both settings is essential to ensure that the discharge and transition of rehabilitation is well-coordinated and coherent (46,47). Premature discharge or discharge to an environment that is incapable of meeting patients’ needs may result in hospital readmission. In addition, providing information to the elderly patients about diagnoses and a plan for further treatment and rehabilitation is important during discharge (48). The time- pressures within a short-stay unit at an ED can present challenges to effective deliverance of such information. Elderly patients in particulare may have a higher risk of poor

understanding because of a high prevalence of communication barriers such as vision and hearing impairments and confusion (48). A qualitative study based on interviews with elderly patients readmitted to hospitals indicated that factors such as lack of information sharing and discharge planning, as well as not reacquiring their habitual levels of functioning before discharge, were the main reasons for readmission (49). Discharge planning is an essential element in optimising discharge and transition of care and rehabilitation to reduce adverse post-discharge events among elderly patients (50). The process of discharge planning strives to ensure that patients are discharged at an appropriate time and that sufficient support is accessible after discharge (51). Factors such as collaboration among healthcare professionals and information exchange have been identified as important in the discharge-planning process and in coordinating a coherent discharge (50–52). A review from 2012 aimed to identify interventions designed to improve patient safety during transitional care, with a particular emphasis on discharge interventions, revealing that interventions that combined discharge planning with primary-care support or follow-up were the most effective (46). Another systematic review from 2016 that aimed to assess the effectiveness of discharge planning concluded, based on its meta-analysis, that a structured discharge plan probably elicits a small reduction in readmissions among elderly patients (53).

Elderly patients’ perspectives on discharge Involvement of the users of the healthcare system is generally recognised as important with regard to improving the quality of healthcare services. Qualitative research among users can lead to important insights into processes of change in both developing and evaluating interventions (54,55). To date, research conducted on EDs predominantly has comprised quantitative studies that address health professionals’ views, whereas little research has addressed patient-perceived factors (56). To improve the discharge process from hospitals, it is necessary to include elderly patients’ perspectives on which factors they perceive as important for their experience of the discharge (57). In a Scandinavian context, some qualitative studies have examined elderly patients’ perspectives in relation to discharge from hospitals (58–60). All three of these studies revealed that after discharge, difficulties in performing activities affected elderly patients’ everyday lives (58–60). Concerns about how to manage activities in their everyday lives after discharge were present in the discharge process among the elderly patients’ (58,59). Some

elderly patients also experienced lack of information and participation in the discharge process, despite their expressed need to be informed (60). The three aforementioned studies were conducted with elderly patients after longer hospitalisation periodes; therefore their experiences with the discharge process may not be directly transferable to elderly patients discharged after an admission to an ED. In addition, little is known about how elderly patients experience their everyday lives after discharge from an ED which may be especially challenging for elderly patients due to the short admission time and limited time available to prepare and coordinate the discharge and transition to primary care rehabilitation.

Identifying limitations in performing activities Assessment of performance of activities is one of the first steps in identifying the need for further rehabilitation in elderly patients before discharge (61). Reports in the medical literature differ with regard to how large a proportion of elderly patients admitted to EDs are limited in performing activities. An Australian cohort study concludes that more than half of the elderly patients discharged from EDs are at risk of limitations in performing activities and suggests that all patients aged 65+ should be assessed before being discharged (25). Other studies reveal that up to two-thirds of elderly patients admitted to EDs are limited in performing at least one daily activity (24,62). The assessment of activity performance can vary considerably. A systematic review including 43 papers on functional assessments utilised in EDs identified 14 different assessment tests (63). However, the review does not provide any information about whether the assessments were based on self-reports from patients or observations from staff during the elderly patients’ EDs stay (63). In some studies, it has been questioned whether self- reported measures of activity performance, as opposed to performance-based measures, provide a valid picture of activity performance (64,65). Studies that have compared self- reported measures with performance-based measures conclude that discrepancies exist between the two approaches (65–69). Although self-reported measures provide information on elderly patients’ habitual performance, elderly patients tend to overestimate their performance (65,67). Since self-reported and performance-based measures seem to provide different, but complementary, information about performance of activities, a combination of the two different approaches may offer some advances (68,70). Performance-based measures seem to be highly relevant in assessing patients’ performance during admission to short-stay

units, while self-reported measures may be relevant when the objective is to assess patients’ habitual performance before admission. Self-reported measures generally may have the advantage in that they are less time- consuming than performance-based measures. However, simple performance-based measures related to mobility, such as gait speed and the ability to rise from a chair, are feasible and easy to apply for all healthcare professionals to use in populations of elderly patients (71,72). In Denmark, the Ministry of Health has developed national recommendations on the use of such measures to identify elderly patients’ need for further rehabilitation (73). Little is known about the use of more complex performance-based measures, especially in ED settings. From an occupational therapy perspective, the focus is not only on whether a person is independent or requires assistance, but also on the quality of that person’s performance of activities (74,75). When occupational therapists assess performance of activities, they consider parameters such as safety risks, efficiency (decreased time-space organisation), independence and physical efforts related to the performance of activities (75). Such parameters are found to be relevant to determining the need for further rehabilitation and/or home care (75,76).

Review of the literature In the initial stage of this PhD project and throughout the process, systematic literature searches were undertaken to identify studies that could inform the development and outcome evaluation of an intervention aimed to reduce risk of readmission in elderly patients. Two different searches were conducted, each with its own specific search question. The first literature search aimed to examine the effectiveness of interventions aiming to reduce the risk of readmission in elderly patients discharge from an acute or emergency department. The second literature search aimed to identify studies that examine the effectiveness of occupational therapy that aimed to enhance older peoples’ performance of activities. In the following section, the results from the literature search will be presented.

Interventions aimed at reducing risk of readmission for elderly patients: The Population Interventions Comparators Outcomes (context) (PICO(c)) was used to guide the structuring of search question and frame inclusion and exclusion criteria (77) (Appendix A). The search was conducted in two phases. First, a search for systematic reviews and meta-analyses was performed. Secondly, a search was performed for single experimental studies of either

randomised (Level I) or non-randomised (Level II) design. The second literature search was performed to identify studies not included in the systematic reviews or meta-analyses, as well as identify single studies in which the descriptions of the applied interventions were not described clearly in the reviews or meta-analyses. Additional references were identified through hand search in the reference lists of relevant papers'. The literature search was performed in the databases PubMed, Embase, CINAHL and Cochrane Database of Systematic Reviews and limited to a population of 65+. The following terms were used as search keywords: discharge combined with readmission, re-visit or rehospitalisation, combined with emergency department or acute. The selection of studies to include was done in three steps. First, titles were assessed and obviously irrelevant studies were excluded. Second, remaining studies’ abstracts were assessed based on their relevance to the search question. Third, the full texts of all remaining studies were screened for eligibility based on the specific inclusion and exclusion criteria. The full search strategy with stated inclusion- and exclusion criteria is presented in Appendix A. Data were extracted using an evidence table that summarised the studies’ methods and findings. Risk of bias in the single experimental studies was assessed by the use of Cochrane Collaboration’s Risk of Bias Assessment tool which asses the five domains: 1) Selection bias; 2) Performance bias; 3) Detection bias; 4) Attrition bias; and 5) Reporting bias (78,79). All domains were assessed as having a high, low or unclear risk of bias. Risk of bias in the included studies is presented in Appendix B.

The literature search identified nine systematic reviews that included interventions that aimed to reduce the risk of readmission in elderly patients discharged from an acute or emergency department. Three of the systematic reviews were conducted as meta-analyses (80–82). The literature search also identified nine single studies on pre-discharge and/or post-discharge interventions that aimed to reduce risk of readmission. In the following tables, an overview of the nine systematic reviews (Table 1) and nine single studies (Table 2) is presented.

Table 1. Overview of reviews and meta-analyses aimed at reducing risk of readmission in elderly patients discharged from an acute or emergency department. Author, Objective Design and Interventions Outcome Results year studies included Conroy et To assess the role of Systematic Hospital-based geriatric assessment or/and Readmission There was no clear evidence of benefit al. 2011 Comprehensive review and home based intervention. Mortality for CGA interventions in any of the (80) Geriatric Assessment meta-analysis. Nursing home outcomes. (CGA) for elderly Included 5 Functional status patients who attend studies. Quality of life acute hospital settings.

Deschodt et To determine the Systematic Inpatient geriatric consultaion teams which Readmission Inpatient geriatric consultation team al 2013 impact of inpatient review and should consist of a least three different Mortality have no significant impact on (83) geriatric consultation meta-analysis. health professionals. The interventionen Length of stay readmission, length of stay or teams on clinical Included 12 consisted of comprehensive assessment and Functional status functional status. However a outcomes of interest in studies. feedback with recommendations, without the significant impact was found for elderly patientss. team being in control of the patient mortality. management.

Fox et al. To compare the Systematic Acute geriatric unit care characterized by Readmission No differences were found regards 2012 effectiveness of acute review and one or more components: Functional readmission, functional decline or (81) geriatric unit care with meta-analysis. Patient-centered care, frequent medical decline mortality. There was a difference usual care. Included 13 review, early rehabilitation, early discharge Hospital stay between the groups regards hospital studies. planning and prepared environment. Nursing home stay, nursing home and costs in favour Mortality of patients receiving the experimental Costs intervention.

Graf et al. Focus is on the use and Systematic Comprehensive Geriatric assessments which Readmission CGA in ED is efficient for decreasing 2011 value of CGA in review. include multidisciplinary evaluation, Mortality readmission, functional decline and (84) emergency department Included 13 examination of comorbidities and Nursing home possibly nursing home admission in (ED) for evaluation of studies, 8 polypharmacy, assessment of risk of falls Functional status high-risk patients There was no effect elderly patients and its studies on and functional status (basic activities of related to mortality. influence on adverse efficiency daily living) and instrumental activities of outcomes. and 14 on daily living as well as nutritional status and screening tools. social support.

Hastings et To evaluate the Systematic They examined the following intervention Readmission The results of trials aimed at al. 2005 evidence for review. types: Mortality decreasing hospital readmission were (85) interventions designed Included 27 *Telephone Follow-up Nursing home mixed. to improve outcomes studies. *Trained Nurse/Team in the ED Quality of life for elders discharged *Rapid Home-based Services Functional status from the ED. *Health Visitors Length of stay

Hickman et To identify Systematic Three intervention components were present Readmission The results demonstrate that al 2015 multidisciplinary team review. across the included studies: Length of stay coordination and clear communication (86) interventions to Included 6 1.Tailored treatment by clinicians with Mortality can have an impact on readmission, optimise health studies. geriatric expertice Functional status mortality and functional status in outcomes for elderly 2.Focus on transitional care interventions elderly patients. patients in acute care that enhance discharge planning. settings. 3.Communication

Karam et al. A systematic review on Systematic They examined the following intervention Readmission More intensive interventions more 2015 interventions within ED review. types: Hospital stay frequently resulted in reduced adverse (9) targeted towards Included 9 *Referral to community based interventions Nursing home outcomes than did simple referral reducing readmission, studies of *Program/follow-up Mortality intervention types. hospitals stay, nursing which 3 were *Integrated model of care home admissions and randomized deaths in older patients trials after initial ED discharge

Lowthian et The aim was to provide Meta-analysis. The interventions included geriatric Readmission Compared with usual care, the al. 2015 robust estimates of Included 9 assessment with referral for post-discharge Mortality evidence indicates no appreciable (82) effect of care models on studies of community-based assistance, that differed Functional benefit regards readmission, mortality, risk of re-admission or which 5 were in components and delivery method. decline functional decline or nursing home. functional decline in randomized Nursing home activities of daily trials. living, nursing home admission and mortality in elderly patients discharged from ED.

McCusker The aim was to Systematic Comprehensive geriatric assessment Readmission Hospital-based interventions had little et al. systematically review review. conducted either as : overall effect on ED readmission, 2006 the literature and Included 26 *Inpatient interventions (hospital) whereas interventions conducted either (22) compare the effects of studies – seven *Outpatient/Primary care interventions as outpatient/primary care or home comprehensive geriatric were using *Home care interventions care settings were beneficial in interventions on samples of ED *Community interventions reducing risk of readmission. emergency department patients of visits. which 4 were randomized trials.

Table 2. Overview of intervention studies aimed at reducing risk of readmission in elderly patients discharged from an acute or emergency department Author, Objective Setting and Design and Intervention Outcome Results year, population follow-up country Caplan et al. To study the effects Emergency Randomized, Patients in the intervention group Readmission Intervention patients had a lower rate of 2004 of a Comprehensive Department Controlled Trial underwent initial CGA and were Nursing home readmissions during the first 30 days after Australia Geriatric followed at home for up to 28 Mortality discharge 16.5% vs 22.2% (p=0.048), after (87) Assessment (CGA) n=739 Follow up at 3, 6, days by a hospital-based Physical 18 month 44.4% vs 54.3% (p=0.007), and intervention on 12 and 18 month multidisciplinary team. The team function longer time to first emergency admission. elderly patients Mean age after discharge implemented or coordinated Cognitive There was no difference in mortality or discharge from the 82 years recommendations. The control function nursing home admissions. Patients in the emergency group received usual care. intervention group maintained a greater department (ED). degree of physical (6 month) and cognitive (12 month) function.

Cossette et To determine Emergency Randomized, Patients in the intervention group Readmission An interim analysis that stopped the study al. 2015 whether a nursing Department Controlled Trial received one patient-nurse with half of the planned sample showed that Canada intervention meeting before discharge and two number of readmissions were similar in (88) delivered at n=265 Follow up 30, 90 additional telephone contacts both groups at 30, 90 and 365 days. emergency and 365 days after over the next two weeks. departments would Mean age discharge. reduce risk of 67 years readmission.

Courtney To evaluate the Acute Randomized, Comprehensive nursing and Readmission The intervention group required MD et al. effect of an exercise- Department Controlled Trial physiotherapy assessment and significantly fewer emergency hospital 2009 based model of individualized program of readmissions, 22% of intervention group Australia hospital and in- n= 128 Follow-up at 4, 12 exercise strategies and nurse- and 47% of control group (p=0.007) and (89) home follow-up care and 24 weeks by conducted home visit and emergency visits, 25% of intervention group for elderly patients Mean age telephone. telephone follow-up at the and 67% of control group (p=0.001). at risk of 79 years hospital and continuing for 24 readmission. weeks after discharge.

Dedhia et To study the Acute Quasi-experimental The intervention had five core Readmission Return to the ED within 3 days of discharge al. 2009 feasibility and Department pre–post study elements: admission form with Patient was lower in the intervention group, 10% vs USA effectiveness of design. geriatric cues, information to the satisfaction 3%, Odds Ratio (OR)=0.25, 95% CI (90) a discharge planning n=422 primary care provider, inter- (0.10;0.62). intervention. disciplinary worksheet to identify At 30 days, there was a lower rate of Mean age barriers to discharge, pharmacist– readmission, 22% vs 14%, OR=0.59, 95% 77 years physician collaborative CI (0.34;0.97) and fewer visits to the ED, medication reconciliation, and 21% vs 14%, OR=0.61, 95% CI (0.36;1.03) pre-discharge planning. in favour of the intervention group.

Guttman et The objective was to Emergency Pre/post design Patients in the intervention group Readmission There was no difference between the groups al.2004 evaluate the impact Department Follow-up at 8 and received a comprehensive regards readmission within 14 days after Canada of an ED-based 14 days after individualized discharge planning discharge, Relativ Risk (RR)=0.79, 95% CI (91) nurse discharge plan n=1724 discharge. implemented by one of three (0.62;1.02). coordinator for elder nurse coordinators. Telephone patients on ED Mean age follow-up were conducted at day revisits. 82 years 1, days 8 and days 14 after the ED visit.

Legrain et To determine Acute Randomized Comprehensive discharge- Readmission 23% of patients in the intervention group al. 2011 whether a new Department Controlled Trial planning intervention which Mortality were readmitted 3 months after discharge, France multimodal consisted of three components: compared with 30.5% of control group (92) comprehensive n= 656 Follow-up 3 and 6 comprehensive chronic patients (p= 0.03). discharge-planning months after medication review, education on Survival was significantly higher in the intervention would Mean age discharge. self-management of disease, and intervention group at 3 months HR= 0.72, reduce emergency 86 years detailed transition-of-care 95% CI (0.53;0.97) but not at 6 months readmissions in communication with outpatient HR= 0.81, 95% CI (0.64;1.04). elderly patients. health professionals or usual care.

Mion et al. To examine the Emergency Randomized Intervention consisted of geriatric Readmission There was no differences in readmission, 2003 effectiveness of a Department Controlled Trial assessment in the ED by an Hospital days hospital days, mortality or health costs. USA model of care for advanced nurse and subsequent Mortality (93) community-dwelling n=650 Follow-up at 30 referral to a community or social Nursing home The intervention was effective in lowering elderly patients at and 120 days after agency, primary care provider, Health costs nursing home admissions at 30 days, 0.7% the emergency Mean age discharge and/or geriatric clinic for unmet versus 3%, OR=0.21, 95% CI (0.05;0.99). department. 74 years health, social, and medical needs or usual care. 18

Pedersen et To reduce the Emergency Quasi Randomised Geriatrician and nurse home visit Readmission Intervention group readmissions were al. 2016 frequency of Department Trial on the day following hospital Mortality significantly reduced compared to controls, Denmark readmissions in a discharge or usual practice. Hospital days 12% vs. 23% (p < 0.001). HR=0.50, 95% CI (94) population of n= 1330 Follow-up 30 days (0.38;0.65). geriatric patients after discharge. Days at hospital was shorter for the admitted to an Mean age intervention group: median (IQR): 2 (1–7) emergency 86 years vs. 3 (1–8) days; p = 0.03. department. No group mortality difference was significant.

Rosted et al. To examine the Acute Randomised A brief standardized nursing Readmission No effect was found on readmission, 2013 effect of a two-stage Department Controlled Trial assessment and intervention was Nursing home admission to nursing home, Denmark nursing intervention carried out after discharge and at Mortality or mortality. (95) to prevent re- n=271 Follow-up 30 and follow-up. Focus in the admission and 180 days after assessment and follow-up were functional decline. Mean age discharge patients unresolved problems. 82 years

The interventions described in the systematic reviews (Table 1), were either pre-discharge (e.g., comprehensive geriatric assessment (CGA), discharge planning, medication reconciliation and/or referral to community-based interventions) or post-discharge (e.g., home visits by nurses and/or GPs and follow-up telephone calls). In general, the evidence was mixed, and only three of the systematic reviews revealed effectiveness regards readmission (22,84,86). In a systematic review from 2011, with the aim to examine the effectiveness of a comprehensive geriatric assessment (CGA), the authors conclude that CGA interventions are effective with regard to ED readmission (84). However, they also conclude that CGA takes too much time to perform routinely at an ED as it includes a multidimensional diagnostic process focused on the elderly patient’s medical, psychological and functional capability in order to develop a coordinated and integrated plan for treatment and follow-up (84). In another systematic review, the authors only found two studies that reported reduced risk of readmission owing to interventions conducted at the ED (22). Both interventions consisted of assessment by a nurse with a short-term liaison with primary-care services (22). The authors behind a systematic review from 2015 describes that their review demonstrate that coordination and clear communication can have an impact on readmission, mortality and functional status in elderly patients (86).

Nine single studies of pre-discharge and/or post-discharge interventions that aimed to reduce risk of readmission were identified (Table 2). Three of the studies were non-randomised trials (90,91,94) of which two (90,94) found significant results in favour of the intervention. The six randomised trials were all assessed as having a low to moderate risk of bias (Appendix B). The identified studies were heterogeneous and showed a great variability in type and duration of the interventions, patient selection, and follow-up after discharge. This may account for the inconsistency of reported results in the studies. However, some trends were seen in those interventions that were beneficial in reducing risk of readmission in elderly patients after discharge. A follow-up home visit after discharge as part of the intervention may be beneficial in reducing risk of readmission (87,89,94). An individualised discharge plan with referral to community-based interventions may also be an important component to include in the intervention (87,92).

In general, the literature review revealed inconsistent results regarding the effectiveness of pre-and post-discharge interventions. Descriptions of the delivered interventions and how

they were developed were sparse, which makes them difficult to replicate. The interventions that were beneficial in reducing risk included a pre-discharge assessment, a discharge plan and post-discharge follow-up visits.

A second literature search was conducted in order to specifically identify occupational therapy interventions aimed to enhance older peoples’ performance of activities in general (not ED specific). The Population Interventions Comparators Outcomes (PICO) was used to guide the structuring of the search question and to frame the inclusion and exclusion criteria (77) (Appendix C). The search was performed in the databases PubMed, Embase and CINAHL, limited to a population of 65+. The following terms were used as search keywords: occupational therapy or enablement or accessibility combined with occupation or activities or daily living or everyday life or activitites of daily living (ADL). The same search strategy was applied to all of the databases. The selection of studies to include was done in two steps. First, all titles and abstracts were screened for relevance by the use of in- and exclusion criteria. Then the remaining studies were read in full text and studies not meeting the inclusion criteria were excluded. The full search strategy with stated inclusion and exclusion criteria is presented in Appendix C. The reference lists of selected papers were also scrutinised for other relevant papers. Systematic reviews and single experimental studies were included. Data were extracted using an evidence table summarising the methods and findings of the studies. Risk of bias in the single experimental studies were assessed by the use of Cochrane Collaboration’s risk of bias assessment tool. All five domains were assessed as having a high, low or unclear risk of bias (78,79). Risk of bias in the included studies are presented in Appendix D.

In the following tables, an overview of the nine systematic reviews (Table 3) and ten single studies (Table 4) is presented.

Table 3: Overview of systematic reviews of occupational therapy interventions aimed to enhance the performance of activities in older people Author, Objective Design and studies Intervention Outcome Results year included Barras et To identify and assess A systematic review Occupational therapy discharge Functional status There is no conclusive evidence to al. 2005 the literature regarding including 12 planning and homebased assessment. Institutionalisation support the effectiveness of (96) discharge planning studies. One review, The interventions were consistent in Readmission occupational therapy home involving occupational 4 randomized the studies and based on assessment in Falls assessment and discharge planning. therapy homebased controlled trials the patients home including: mobility, Quality of life assessments. (RCT) and 7 access, safety, kitchen, transfer and Frequency of visits descriptive studies. toileting.

Berger et To assess the A systematic review Intervention types were classified in A variety of There is strong evidence that al effectiveness of health including 36 one of the following: outcomes measures disease self-management programs 2018 promotion, studies. *Disease self-management programs such as: or group interventions has an impact (97) management and (coping, problem solving and exercise) Occupational on occupational performance. There maintenance *Group interventions performance was also strong evidence in favour interventions to *Individual interventions Quality of life of individual health promotion improve occupational *Combined groups and individuals Health care interventions over an extended performance, quality of utilisation period. Moderate evidence for life and decrease health enhancing occupational care utilisation for performance was found for community dwelling combining single and groups older people. interventions.

De To assess the A systematic review The study included trials reporting on Mobility The pooled result for functioning in Coninck effectiveness of and meta-analysis occupational therapy as intervention Functioning in daily daily living activities was a et al. occupational therapy to including 9 studies. (one study), or as part of a living activities standardized mean difference of - 2017 improve performance multidisciplinary approach (eight Social participation 0.30, 95% CI (-0.50;-0.11), for (98) in daily living activities studies). All interventions were Fear of falling social participation -0.44, 95% CI in community-dwelling individually homebased and consisted Cognition (0.69;-0.19) and for mobility -0.45, physically frail older of assessment, education, prevention Disability 95% CI (-0.78;-0.12).There is people. strategies, exercise, home hazard Falls strong evidence that occupational modification, advice on aids and therapy improves functioning in service. Number of occupational community-dwelling physically therapy interventions differed from 1-7. frail older people. 22

Hunter et What is the evidence A systematic review Intervention types were classified in Instrumental The results revealed that there is al. for the effect of and meta-analysis one of the following: Activities of Daily strong evidence that cognitive 2018 interventions within the including 14 *Cognitive interventions Living (IADL) interventions were able of (99) scope of occupational studies. *Self-management Activity enhancing IADL performance and therapy on the *Prevention participation that prevention interventions could performance of IADL *Home-based multidisciplinary Quality of life prevent deterioration in IADL for community rehabilitation performance. Strong evidence was dwelling older people. also found in favour of multidisciplinary intervention to enhance IADL performance. There is moderate evidence that self-management programs improve the level of activity participation.

Liu et al What is the evidence A systematic review The intervention approach for older ADL The benefits of using task-specific 2018 for the effect of including 43 studies adults with difficulties in ADL were exercise to improve ADL outcomes (100) interventions to (16 studies with either: in older people with ADL improve ADL older adults with *Physical exercise (5 studies) difficulties was moderate, while the outcomes for ADL difficulty) *Home-visits or home based (6 studies) benefit of using home visits or community-dwelling *Multicomponent programs (2 studies) home-based intervention was high. older people. *Additional occupational therapy (2 studies) *Multidisciplinary team (1 study)

To synthesizes the Systematic review Occupational therapy aiming at ADL A significant difference in ADL evidence for the including 8 papers, improving occupational performance, performance was found post effectiveness of reporting 6 studies primarily through the practice of intervention but not on long-term Nielsen occupation focused and of which two was activities and tasks. Number of for older people with non- specific et al. occupation based concerning older occupational interventions was up till diagnosis 2016 occupational therapy people with non- five in one study and a mean 1,9 in the (101) for older people (60+) specific diagnosis other study at home

Orellano The aim was to Systematic review The interventions were divided in: IADL Within occupation based and client- et al. examine the including 38 studies 1. Occupation-based and client-centred centred interventions, the evidence 2012 effectiveness of interventions (only OT or that multi-component interventions (102) occupation- and multicomponent) improve and maintain IADL activity-based 2. Functional activities interventions performance in community- interventions on the (functional task exercise programs and dwelling older people is strong. The performance of simulated IADL programs) evidence is moderate for functional selected instrumental 3. Performance skills interventions task exercise programs and limited activities of daily (interventions that target specific for simulated IADL interventions. living for community- performance skills, e.g., physical The evidence for performance skills dwelling older people. activity, cognitive skills) interventions were mixed and there 4. Home modifications and assistive was no evidence for interventions technology related to home adaptations or assistive devices

Stark et The aim was to Systematic review The home modification interventions Functional Strong evidence was found in al. explore the evidence including 36 targeting older people included: performance favour of home modification 2017 for the effectiveness studies. Seven Recommendation of modifications Caregiving interventions are an effective (103) of home modification studies investigated Installation of smart home technology Falls treatment to improve functional interventions for interventions for Training with equipment and assistive performance for older people with adults and older older people with a technology a variety of conditions. people. variety of conditions

Steultjens To determine whether Systematic review, Interventions were classified into Falls There is strong evidence for et al. occupational therapy including 17 studies specific categories: Quality of life efficacy of advising on assistive 2004 improves outcome for a) training of sensory-motor functions; Functional ability devices as part of home hazard (104) older people (60+) who b) training of cognitive functions; assessment on functional ability and live independently c) training of skills; some evidence for the efficacy of d) advice and instruction regarding the skills training combined with the use of assistive devices; and use of assistive devices on the e) counselling of primary care incidence of falls. There is evidence for the efficacy of a home assessment with incorporation of the provision of assistive devices on increasing functional ability.

Table 4: Overview of occupational therapy interventions aimed at enhancing the performance of activities in older people Author, Objective Setting and Design and Intervention Outcome Results year, population follow-up country Abizanda To compare the Acute geriatric unit. Randomized, Intervention included needs Functional ability The adjusted relative risk of et al. benefits of a short term controlled trial assessment, retraining in activities measured with functional ability in the OT 2011 occupational therapy (Intervention=198) of daily living, and instructions for Barthel-Index group was 1.16 95% CI Spain intervention when (Control=202) Follow-up at caregivers in three groups of Reduction in (0.91-1.47). Participants in (105) added to the discharge patients defined a priori confusional the intervention group had a conventional treatment Mean age 83 years (cardiopulmonary disease, stroke, episodes reduction in confusional model. other conditions) 5 days a week, episodes; RR= 0.48, 95% 30-45 min a day. CI (0.26;0.87).

Clemson To determine whether Acute and medical Randomized HOME intervention that included Activities of daily There was no difference et al. an occupational hospitals wards controlled trial in-hospital interview and living measured between groups in ADLs 2016 therapy discharge assessment, client-centred goal with Nottingham (NEADL): β=-0.17, 95% CI Australia planning intervention (Intervention=198) Follow-up after setting, and one pre- and one post- Extended activities (-0.99;0.66) or participation, (106) would be superior to a (Control=202) 90 days discharge home visit. Furthermore of Daily Living β=-0.23, 95% CI usual care intervention two telephone follow-up was scale (NEADL) (-2.05;1.59). There was no to individuals Mean age 80 years conducted at 2 and 4 weeks. Participation difference between groups receiving acute care. Readmission in the number unplanned readmissions

DeVrindt To examine the Community care Single blind Client-centred and activity Basic Activities of The intervention group et al. effectiveness of a RCT oriented intervention: Daily Living (b- experienced more 2015 client-centered and (Intervention =86) a)Training of functions/skills ADL) improvement on b-ADL Belgium activity oriented (Control =82) Follow-up at b)Education of caregiver Health-related (p=0.013) and HRQol (107) intervention for frail discharge c)Use of assistive devices quality of Life (p=0.049) compared to community living Mean age 80 years Intervention period were 8-10 (HRQoL) controls. older people. weeks and one third of the participants received more than two visits. Mean time spent on a participant was 134 minutes.

Gitlin et To test the efficacy of Community care Randomized Occupational and physical therapy Primary outcomes At 6 months, intervention al. a multi-component controlled trial sessions to instruct participants in were self-report participants had less 2006 intervention to reduce (Intervention =160) compensatory strategies, home measures of difficulty than controls with USA functional difficulties, (Control =159) Follow-up at 6 modifications, home safety, fall functional IADL (P=0.04) and ADL (108) fear of falling, home and 12 months recovery techniques and balance difficulties in terms (P=0.03) hazards and enhance Mean age 79 years and muscle strength exercises. 5 of Instrumental self-efficacy and occupational therapy contacts and Activities of Daily adaptive coping in 1 physiotherapy contact in the Living (IADL) and older people with active intervention period Activities of Daily chronic conditions Living (ADL)

Lannin et The aims was to Rehabilitation unit Randomized Participants were randomly Performance of The ability to perform al investigate the controlled assigned to receive either a pre- activities measured activities of daily living as 2007 feasibility of a (Intervention=5) feasibility trial discharge home visit by Functional measured by the NEADL Australia randomised controlled (Control=5) (intervention), or standard practice Independence was higher in the home visit (109) trial in a clinical Follow-up at 2, in-hospital assessment and Measure (FIM) and group by an average of 16 setting and the effect Mean age 81 years 4, 8 and 12 education (control). The pre- NEADL points at 2 weeks (p=0.012) of pre-discharge home weeks discharge home visit involved and by 23 points at 2 visits on functional assessment of the elderly patients months (p=0.003). There performance in elderly function and environment, and were no improvements of patients undergoing education, and took an average 45 the FIM rehabilitation. minutes.

Nielsen et To examine whether Community care Randomized The aim of the intervention was to The primary After 3 months, the al. 11 weeks of intensive controlled trial improve occupational performance outcome was self- intervention group had 2018 client-centred (Intervention=59) by practising the necessary tasks. rated occupational improved 1.86 points on Denmark occupational therapy (Control=60) Follow-up at 3 The intervention was tailored to performance COPM performance; the (110) was superior to usual and 6 months the individual and built on assessed with the Usual-Practice group had practice in improving Mean age 77 years acquisitional, adaptive and Canadian improved 0.61 points. The the occupational restorative models. The Occupational between-group difference performance of home- participants in the intervention Performance was statistically significant dwelling older people. group received on average 11 Measure (COPM) 95% CI (0.50;2.02), t-test: hours of occupational therapy p= 0.001.

Shearer et The aim was to Geriatric unit Pilot study, The programme included personal Functional status No difference in the change al. investigate whether Randomized ADL (e.g., showering, dressing, measured by of total Barthel Index score 2013 individualised (Intervention=22) controlled trial grooming and toileting), simple Barthel-Index between control and Australia activities of daily (Control=26) domestic tasks (e.g., hot or cold Length of hospital intervention groups. No (111) living retraining drink preparation, toast stay evidence was found for a improve functional Mean age 86 years Follow-up at preparation) and functional difference in length of stay outcomes, influence discharge ambulation (i.e., ambulation in the between intervention and discharge destinations context of an ADL. The control groups. and reduce length of intervention group received stay for elderly training three times per week for patients in acute care. one hour.

Tuntland The aim was to Community care Randomized The intervention group received Self-perceived There were significant et al. investigate the controlled trial home-based rehabilitation. The activity improvements in mean 2015 effectiveness of (Intervention=31) therapists supervised the homecare performance and scores favouring reablement Norway reablement in home- (Control=30) Follow-up at 3 personnel, in how to encourage satisfaction with in COPM performance at 3 (112) dwelling older people and 9 months and assist the person in the daily performance - months with a score of 1.5 compared with usual Mean age 79 years training. The focus were on COPM points (p = 0.02), at 9 care in relation to daily training in daily activities, Physical capacity months 1.4 points (p = 0.03) activities, physical adaptations to the environment or Health-related and overall treatment 1.5 functioning, and the activity, and exercise. Mean quality of life points (p = 0.01). health-related quality length of intervention was 10 of life. weeks.

Whitehead The objective was to Community care Feasibility RCT In addition to usual care, a targeted ADL (Barthel Index There were improvements et al test the feasibility of ADL programme, delivered by an and NEADL) from baseline in both 2016 conducting a (Intervention=15) Follow-up at two occupational therapist Quality of life groups, although overall United randomised controlled (Control=15) weeks, 3 and 6 incorporating goal setting, Falls improvements were greater Kingdom trial of an intervention months teaching/practising techniques, Use of health and in the occupational therapy (113) targeted at activities of Mean age 83 years equipment/ adaptations and social services intervention group. daily living delivered provision of advice/support. A by an occupational median of 5 home visits was therapist, in homecare provided and a median length of reablement. intervention period was 56 days

Wressle et The aim was to Acute care unit Pilot study, The intervention consisted of: Ability to perform There was no difference al. evaluate whether Randomized Prescription of assistive devices activities measured between the groups in 2006 occupational therapy (Intervention=22) controlled trial Reports to primary care with structured managing at home after Sweden interventions in acute (Control=19) ADL assessment/training questionnaire discharge. (114) care could improve the Information/instruction elderly patient’s Mean age 83 years Follow-up at 3 Planning of discharge perception of ability to months Training of physical function manage at home after Contact with relatives discharge

Nine systematic reviews were identified (Table 3), of which one review aimed to examine the effectiveness of interventions including discharge planning and occupational therapy homebased assessment (96). The review included 12 studies and identified minimal evidence, primarily due to a lack of high quality studies. The interventions were based on assessments in elderly patients’ homes including: mobility, access, safety, kitchen activity, transfer and toileting. The other eight identified systematic reviews evaluated the effectiveness of occupational therapy for community-dwelling older people (97–104). Five of the systematic reviews concluded that moderate or strong evidence supported using occupational therapy that aimed to enhance older people’s performance of activities when the interventions conducted were activity-based (e.g., practicing activities that were limited) (98,100– 102,104). In a review that included 14 studies, the authors found strong evidence that occupational therapy, as part of a multidisciplinary intervention, can enhance the performance of instrumental activities in daily living among community dwelling older people (99). In a review conducted in 2017, the authors found strong evidence that home- modification interventions can improve activity performance among older people with a variety of conditions (103). In a systematic review of 36 studies, Berger et al. found strong evidence that self-management programmes that include coping strategies, problem solving and exercise improved activity performance (97). In studies included in the systematic reviews, the duration and frequency of interventions varied, from one session to nine within a time frame of up to nine months. Ten studies (Table 4) that aimed to enhance elderly patients’ or older people’s performance of activities also were identified during the literature search. Five of the studies were conducted in hospital settings (105,106,109,111,114), of which two involved home visits (106,109). In a sample of 400 elderly patients, Clemson et al. examined the effectiveness of an occupational-therapy planning intervention, including pre- and post-discharge home visits, but they did not find evidence that the intervention enhanced activity performance (106). In their feasibility study with 10 elderly patients, Lannin et al. found that a pre-discharge home visit significantly enhanced the performance of activities by two and eight weeks (109). In the other three studies conducted in a hospital setting without home visits, no positive effects on activity performance or any secondary outcomes were found. The duration and frequency of the interventions varied, from a single session lasting one hour to several sessions lasting 30 to 45 minutes each, five days a week, for two weeks (105,111,114). In four of the five studies conducted in primary care settings, significant differences in performance of activities

in favour of occupational-therapy intervention groups were reported compared with the usual practice (107,108,110,112). The frequency and duration of the interventions varied, from a single session to 15 sessions over an 11-week period, indicating broad variance in doses and intervention duration

Summary of background One of the most serious and adverse events for elderly patients after being discharged from hospitals is readmission. Elderly patients’ performance of activities and a coherent discharge to their homes are essential factors that influence elderly patients’ risk of readmission and thus may be highly relevant to address in interventions aimed at reducing risk of readmission after discharge from a short stay unit at the ED. The primary focus when people are admitted to a short-stay unit at an ED is on treating illnesses with less attention paid to elderly patients’ limitations in performing activities and need for rehabilitation post-discharge. The role of occupational therapists in a short-stay unit at the ED is to identify patients with limitations in performing activities and to coordinate the discharge and referral to post-discharge rehabilitation in primary care. However, further research on the effectiveness of such interventions is required. Occupational therapy interventions that focus on enhancing community dwelling older peoples’ performance of activities reports some to strong evidence in favour of occupational therapy interventions, while the research on occupational therapy interventions initiated in acute hospital settings is sparse.

Coordinated, consistent information exchanges and collaborations among healthcare professionals have been identified through the literature as important for a coherent discharge. However, studies on discharges from EDs are most commonly examined from a health professional or societal perspective and do not include the elderly patients’ experiences. Identifying factors of importance for the elderly patients’ experience of being discharged and returning to everyday life may contribute with new knowledge to guide future discharge of elderly patients.

3. Aims and hypotheses The overall aim of the present PhD project was to improve and inform current practices regarding the discharge of elderly patients from a short-stay unit at an ED in order to reduce their risk of readmission. The dissertation builds on two studies, each with its own specific aim. The two studies are reported in three paper.

Study I Aim Ia: To develop and describe a short-term intervention that aimes to reduce elderly patients risk of readmission after discharge from a short-stay unit at the ED (1).

Aim Ib: To examine the clinical effectiveness of a developed intervention in reducing risk of readmission in elderly patients discharged from a short-stay unit at the ED (2). Hypotheses: The primary hypothesis was that the intervention would be superior to usual practice in reducing risk of readmission within 26 weeks after discharge. The secondary hypotheses were that the intervention would be superior to usual practice in reducing risk of readmission within 30 days, would reduce mortality within 26 weeks, and would reduce the number of contacts to general practitioners and EDs within 26 weeks. It was hypothesised further that the time to readmission would be longer for patients in the intervention group than for patients in the usual practice group.

Study II Aim: To add to the knowledge base concerning elderly patients` experiences of being discharged and of returning to their everyday lives after discharge from a short-stay unit at the ED, in order to understand which factors they find of importance during and after discharge (3).

4. Methodology and methods

Design This project’s overall research design was a multimethod design that included both quantitative and qualitative strands (115). Using a multimethod design is based on the realisation that no single research method would have been sufficient to support the complexity of this PhD project’s overall aim. The multimethod design does not mix quantitative and qualitative data in the collection or analysis phases of the study and are thus different from a mixed method design (115). In this PhD project, the multimethod design comprise two distinct stages. In the first stage the Elderly Activity Performance intervention (EAP intervention) was developed and retrospectively described. In the second stage, an outcome evaluation of the effectiveness of the EAP intervention (Study Ib) and qualitative interviews (Study II) with elderly patients receiving the intervention were carried out concurrently. The results from the two studies are integrated in the discussion section of this dissertation. The specific aims of the two included studies defined the methodology and methods used in each study and are described in more detail below.

Figure 1. Overview of the three studies in the PhD project Stage 1 Stage 2

Study Ia: Development of the EAP Study Ib: Outcome evaluation intervention of the EAP intervention

Integration in the discussion of the dissertation

Study II: Description of elderly patients’ experiences

TThThheory and Theory and evidence-based literaturebased literature

Study I comprised two parts. In the first part (Study Ia), the EAP intervention was developed and in the second part (Study Ib) an outcome evaluation of the effectiveness of the developed intervention was conducted. According to the Medical Research Council’s guidance for the development and evaluation of interventions, a clear description of how the intervention was developed is needed to allow for replication and avoid "black boxes" in which effective or non-effective ingredients are unknown (54). A detailed description of the intervention components and their underlying theory and evidence was reported retrospectively in Paper I using the intervention mapping approach. This, also included a detailed description of how to implement and evaluate the effectiveness of the intervention (117). The outcome evaluation of the effectiveness of the developed intervention was conducted pragmatically as a non-randomised, quasi-experimental, superiority trial comparing an intervention- and a usual practice group. Quasi-experimental designs utilise structures similar to those used in a randomised controlled trial; however, due to the lack of random assignment, the degree of control is limited and the risk of bias increases. Therefore, the conclusions drawn from such a study must therefore take into account the potential biases of the selected sample (118). Although the quasi-experimental trial has some limits, it also has some advantages. Quasi-experimental trials accommodate for the limitations of natural settings where random assignment may be difficult or impractical (118). The choice of a quasi-experimental trial design was based on experiences from a previous minor study, designed as a randomised controlled trial, performed in the same short-stay unit (not published). The outcome evaluation of the previous study revealed that it was difficult to recruit patients in the defined time period, as 67% of eligible patients refused to participate. One of the principal reasons that patients cited in their refusal was the randomisation procedures, as they had to agree to participate before knowing which group they would be assigned to. Therefore, we chose to design our full scale experimental study as a non- randomised quasi-experimental trial (54,119). Study II was a qualitative interview study conducted concurrently with the outcome evaluation in Study Ib, and it included patients who received the EAP intervention. Individual interviews were conducted in order to gather descriptions of elderly patients’ experiences of being discharged and returning to everyday life. This was done to identify the factors that elderly patients view as important during and after discharge from a short-stay unit at the ED.

Theoretical perspectives The methodology and methods used to address the aim of this PhD project builds on theoretical perspectives that inform the research process. Crotty describes theoretical perspectives as "the philosophical stance informing the methodology and thus providing a context for the process and grounding its logic and criteria" (119, p.3).

As this PhD project uses both quantitative and qualitative methods in a multimethod design, it builds on different theoretical perspectives. In Study I, post-positivist perspectives underlie the methodology and methods. Knowledge is based on cause-and-effect thinking focusing on detailed observations and measures of variables, and generalisability is sought (121). Post- positivism recognises that all observations are fallible, and that theories can be modified (120). The methodological approach in the qualitative study (Study II) was inspired by Giorgi's phenomenological descriptive method, which is based on the phenomenological philosophy of Husserl (122,123). The phenomenological philosophy focuses on human beings and their life world. The inspiration from Giorgi’s method was based on its suitability for describing individuals’ experiences as expressed by themselves by putting aside past knowledge concerning the phenomenon of interest (122,124). According to Giorgi’s phenomenological descriptive approach, experiences can be described and understood in terms of how people perceive them and that they should not necessarily be interpreted (124–126). Through the qualitative study, we sought to understand how elderly patients experienced their discharge and their everyday lives after discharge. The description of these experiences focuses on what is essential and meaningful for the person who has these experiences. To do so, researchers need to bracket their preconceptions, which can be approached in different ways (122). My preconceptions were based on clinical experiences with the population of interest, empirical research concerning the population and problem and theoretical assumptions concerning activity limitations. When conducting the qualitative interviews and the analysis, my preconceptions were shared and continuously reflected upon with senior researchers and before conducting the interviews, they were written down to ensure transparency and reflexivity.

Study population Recruitment of eligible patients to the two studies took place at the short-stay unit at the ED at Aarhus University Hospital, Denmark. Patients in study II were included from the sample in study I. Inclusion- and exclusion criteria for participants in the two studies are presented in Table 5.

Table 5. Inclusion- and exclusion criteria for the study population Inclusion criteria: Patients with medical diagnoses admitted on weekdays to the short-stay unit at Aarhus University hospital Age 65+ Residents in the Municipality of Aarhus

Exclusion criteria: Patients transferred to other hospital departments from the short-stay unit Patients admitted from a nursing home Patients declared terminally ill Patients unable to communicate in Danish

As the overall aim was to improve and inform current practices concerning elderly patients’ discharge from a short-stay unit at the ED, all patients transferred to other hospital departments were excluded. Patients admitted from nursing home were also excluded, as their access to municipal rehabilitation services was different from that of home-dwelling older people admitted to hospital. One of the factors addressed in the intervention was the coordination between the hospital and primary care. A plan for such coordination was an integrated part of the intervention developed and evaluated in study I. This coordination was especially developed between Aarhus University hospital and the Municipality of Aarhus. Therefore, only residents in the Municipality of Aarhus were included.

Methods study Ia: Development and description of the intervention The intervention was systematised and described through the use of the Intervention Mapping approach, which describes the iterative path from problem identification to problem solving (117). Originally, Intervention Mapping was used in health promotion programmes ranging from HIV prevention, to overweight management, to physical activity motivation (117).

The Intervention Mapping approach provides a methodological, step-by-step procedure and comprise six steps with several tasks. The first two steps involve the description of a needs assessment and the intervention’s objectives. In Step 3, theory- and evidence-based methods and strategies are selected, which then inform the intervention developed in Step 4. Steps 5 and 6 describe the plan for implementation and evaluation of the developed intervention (117). The Template for Intervention Description and Replication (TIDieR) checklist was consulted to ensure that the final intervention was described sufficiently (127). In the following steps, the methods used in the development of the intervention are described using the Intervention Mapping approach as a framework to enhance the transparency of the process (117). The methods used in the development of the intervention will be outlined briefly in this method section, while the results of Steps 1-4 are presented in the results section. Steps 5 and 6 are outlined in the Appended Paper I.

In Step 1, a needs assessment was conducted to identify and describe risk factors for readmission, underlying behavioural and environmental factors that could affect risk factors, and determinants for behavioural and environmental factors. The needs assessment primarily was based on findings from the literature and informal consultations with two occupational therapists and two physiotherapists from the hospital and primary care sectors who contributed their clinical experience concerning the population. The needs assessment was conducted later in the process and structured with a logic model, as recommended in the Intervention Mapping approach (117). To bring expertise into the project, a steering group, project group and reference group were established. The steering group was responsible for the project’s success, comprising 11 experts from both the hospital and primary care. Five of these experts comprise the project group, including the project leader (PhD candidate). The project group was responsible for planning, implementing and evaluating the intervention. Finally, a reference group of physiotherapists and occupational therapists from the ED contributed information about the clinical context.

In Step 2, a basis for the intervention was established by specifying overall outcomes and dividing them into separate performance objectives of the intervention. The performance objectives explicitly described what should happen to achieve the outcome (117). Then the most important internal (relating to the person) and external (relating to the environment) determinants identified in Step 1 were combined with the specified performance objectives to

formulate change objectives, which specified what would change in the determinants as a result of the intervention and were required to achieve performance objectives and the overall outcome.

In Step 3, different literature searches were undertaken. First, we searched for tests to assess limitations in elderly patients’ performance of activities (See Appendix E). Tests were selected on the basis that they were performance-based, generic tests that were validated for the older population and simple to administer in a clinical setting. Next, we searched systematically for studies that examined the effect of interventions that aimed to reduce readmission risk among elderly patients discharged from an acute-care or emergency department (See Appendix A). Theoretical and evidence-based literature concerning occupational therapy also was identified in this step to inform the intervention. Decisions about specific methods and suitable strategies to include in the intervention were made within the project group and in conjunction with the reference group.

In Step 4, specific intervention components were created by combining and sequencing the methods and strategies identified through literature searches in Step 3. In total, three components were developed. A description for delivering the components was developed, and Component 1 was examined during a two-week period within a population of elderly patients admitted to the short-stay unit at the ED. The tests in Component 1 were examined to consider whether they were viable in an acute setting and to train therapists in how to perform the tests in a standardised manner. During the examination period, the project leader supervised the therapists to ensure that the tests were used as described in the test manual. The description of how to deliver the intervention also included a checklist to be used within Component 3.

Methods study Ib: Outcome evaluation of the intervention Setting and recruitment of study participants The study took place from March to December 2014 at the short-stay unit at the ED at Aarhus University Hospital. Each weekday at 8 a.m, a research occupational therapist reviewed a list of all patients admitted during the previous 24 hours and screened for eligibility. The allocated resources allowed us to include and allocate a maximum of two

patients for the intervention group per day. If more patients were eligible, allocation was based on the date of birth (day of the month). The two patients born closest to the first day of a month (e.g. 1 March) would be allocated to the intervention group, and others to the usual practice group. Patients admitted after 8 a.m. who met the inclusion criteria but were discharged out of hours (during afternoons and evenings) could not be allocated to the intervention group, because the research occupational therapists were not present later in the day/evening to include and assess them before their discharge. Instead, these patients were allocated to the usual practice group. Patients allocated to the intervention group were provided with verbal and written information about the study. Patients agreeing to participate signed a consent form. Patients allocated to the usual practice group were not informed about their participation, because only data from the National Patient Registry were used. Instead, the National Board of Health gave permission to obtain health-related data on patients in the usual practice group.

Interventions provided Usual practice: Patients in both groups received the standard course of medical treatment and care at the short-stay unit at the ED. Referral to occupational therapy and physiotherapy took place only if the medical doctor or nurse considered it necessary. If the occupational therapist was summoned to asses a patient, the occupational therapist performed a short interview and a non-standardised observation of the patient’s performance of activities in relation to self-care with results communicated to municipal homecare staff. If necessary, ED nurses organised referrals to home health care after discharge.

Elderly Activity Performance (EAP) intervention: In addition to the standard course of treatment delivered at the short stay-unit at the ED, patients in the intervention group received the developed EAP intervention (described in the results section).

Intervention fidelity Three occupational therapists and two physiotherapists delivered the intervention after having participated in a one-day training course that introduced them to the intervention. The content of the one-day training course included an introduction to the components of the intervention combined, with the rationale for the choice of components. The course also included education in the assessments in Component 1 and introduced a plan for a two week programme that aimed to train the therapist in delivering the assessments. The

physiotherapists were only part of delivering Component 1, while the occupational therapists delivered all three components. During the recruitment period, weekly meetings were organised between the participating research therapists and the project leader with the objective of discussing and solving potential problems related to either recruitment of participants and/or intervention delivery. This was done to enhance intervention fidelity. To examine whether the EAP intervention was delivered as intended, the number of patients receiving different intervention components was registered.

Data collection and measures Data used in study I compromised both patient reports and data from national registries. An overview of the different data sources and data is given in Table 6.

Table 6. Data sources and data used in study I Data source Data The Danish Civil Registration System Civil status Date of birth Date of death Gender Age The Danish National Patient Register Admission date and time Discharge date and time Readmission date and time Diagnosis Comorbidity Contacts to emergency department National Health Insurance Service Register Contacts to general practitioner Contacts to emergency physician Questionnaire Performance of activities, WHODAS 2.0

At baseline and at 30 days and 26 weeks’ follow-up, all patients in the intervention group were interviewed using a structured interview questionnaire. Although the design of the study did not allow a between group comparison of changes in self-reported activity performance, we wanted to measure and describe possible changes within the EAP intervention group. Self-reported activity limitations during the previous 30 days were measured with the World Health Organisation Disability Assessment Schedule (WHODAS 2.0), a generic assessment for measuring functioning and disability in accordance with ICF (128,129). WHODAS 2.0 covers the six domains: cognition, mobility, self-care, getting along, life activities and

participation. During the interview, respondents are asked questions about the degree of difficulty that they experience in doing different activities. Having difficulty with an activity means experiencing at least one of the following: 1) increased effort, 2) discomfort or pain, 3) slowness, 4) changes in the way the person does the activity. The score used in this study was the simple summary score of 32 items with a maximum score of 160, which indicates severe disability. The psychometric properties of WHODAS 2.0 seem strong, including good reliability, responsiveness and concurrent validity (128,129). WHODAS 2.0 was chosen as we wanted a self-reported measure that was capable of measuring limitations in activity performance in a broader sense than degree of dependence/independence.

Baseline data, including gender, age, civil status, admission time and comorbidity calculated with Charlson's Co-morbidity Index (CCI) were extracted for patients in both groups (130– 132). These data were obtained through national registries (see Table 6). The primary outcome was risk of first-time all-cause readmission within 26 weeks. Readmission was defined as an acute admission at least 4 hours after discharge in accordance with former studies (94). Although several studies use 30-day readmission as outcome, a follow-up time of 26 weeks was considered more appropriate, as limitations in performing activities may not be improved in such a short time frame as 30 days (33,133). Secondary outcomes were risk of first-time 30-day all-cause readmission and all-cause mortality, number of contacts to GPs and EDs within 26 weeks, and time to first readmission. All data on outcome variables were obtained through national registries.

Data analyses All analyses in study I were performed using the Stata 14.2 statistical program. Hypothesis tests were conducted at the 5% level of significance, two-sided. Although the study used a non-randomised allocation, the reporting of the study complied with the Consolidated Standards of Reporting Trials (CONSORT) guidelines to ensure transparent reporting (134). The study was registered in Clinicaltrials.gov (NCT02078466). The Biostatistical Advisory Service from Aarhus University was consulted during the development of the analysis plan and during the analyses.

Sample size calculation: Based on the literature, the intervention was expected to reduce the risk of readmission within 26 weeks with 16 percentage points, from 37% to 21% (135). Power calculation revealed that the sample size should be 304 patients allocated equally (1:1), assuming that 10% of the participants were lost to follow-up, e.g. due to death, with a two-sided significance level of 5% and a statistical power of 80%.

Description: A descriptive analysis was performed summarising baseline characteristics for both the intervention group and the usual practice group. Data were presented by mean and standard deviation (SD) or number and percentage. The two groups were compared and tested for significant differences using chi-square test for categorical variables, Student’s t- test for normally distributed continuous variables and the Wilcoxon rank sum test for non- normally distributed variables. This was necessary due to the non-randomised design, where it was not possible to assume that potential confounding was evenly distributed between the two groups (118,136). Also, an explorative analysis was performed to compare baseline differences for those patients in the usual practice group admitted during the day-time and those admitted during afternoon and evenings in order to include possible differences in the adjusted analyses.

Primary analysis: The analysis was performed according to the intention to treat principle, regardless of the amount of intervention received. Risk of first-time readmission within 26 weeks was estimated by cumulative incidence proportion using a pseudo-value approach accounting for death as a competing risk (137–139). In the pseudo-value approach, a new set of pseudo observations are generated to boost the number of cases in the analysis to be used in a generalised linear model. The two groups were compared by risk difference (RD) and risk ratio (RR) with 95% confidence intervals (CI), as described in the CONSORT guidelines (134). Due to the non-randomised study design, a similar analysis was performed by adjusting for factors that a priori were considered to be potential confounders: age, gender and co-morbidity. Also differences in baseline variables between the two groups were included in the adjusted analysis. Secondary outcomes were 30-day all-cause readmission and all-cause mortality within 26 weeks, which were estimated by RD and RR with 95% CI and secondly adjusted for potential confounding. Time to first readmission with unadjusted cumulative incidence proportions was illustrated in a graph. Number of contacts to GPs and

the ED were described with medians and range and differences were tested with nonparametric Wilcoxon rank sum tests.

Analyses within the EAP intervention group: An exploratory analysis within the EAP intervention group was performed to examine whether the number of intervention components received was associated with risk of readmission. Self-reported limitations in performance of activities measured with WHODAS 2.0 was described for the EAP intervention group at baseline, 30 days and at 26 weeks’ follow-up by simple summary scores.

Methods study II: patients’ perspective Recruitment of study participants Patients were recruited among those patients allocated to the intervention group in Study Ib between 15 October 2014 and 20 November 2014. No established method of determining sample size seems to exist within qualitative research, although it has been suggested that an approximation of sample size is necessary for planning a study (140). Therefore, when preparing the study and its time frame for data collection, it was determine in advance that the number of participants should be between 10 and 15, in accordance with a phenomenological approach in which we intended to rely on in-depth, rich data rather than number of participants (141). We sought to achieve data that were detailed, nuanced and of sufficient quality (142). Purposive sampling was used to ensure variety in diagnosis, age, gender and material status as these aspects could contribute to the data’s richness (142). The occupational therapists delivering the intervention in Study Ib undertook the sampling in collaboration with the project leader. Shortly before discharge, 15 elderly patients were invited to participate and were given written information about the study’s purpose. Thirteen gave their oral consent to be contacted after discharge. Approximately one week after discharge, patients were contacted by phone and verbal information was provided. Eleven elderly patients gave their informed and written consent to participate.

Data collection Individual interviews by the same interviewer were conducted with 11 elderly patients receiving the EAP intervention in Study Ib. The interviews lasted 30 to 60 minutes each and took place in the elderly patients’ homes two weeks after discharge. A semi-structured interview guide with primarily open-ended questions was used in order to have a specific set of instructions to stay focussed on the topic while simultaneously striving to encourage the patients to describe their experiences. Although the qualitative study was inspired by Giorgi’s descriptive phenomenological method, Giorgi offered no advice on how the interviews should be conducted other than via open-ended questions (122,123,125). Instead, we found inspiration from Kvale and Brinkmann, who outlined phenomenology as a basis for their approach to qualitative interviewing (143,144). Kvale and Brinkmann outline that questions should aim to describe specific situations and actions, not general opinions and suggested using a semi-structured interview guide to structure the interview (143,144). The interview guide was developed with four themes, starting with a preliminary question concerning the experience of being admitted to hospital (Table 7). This was done to encourage participants to tell their stories about what led to their admission. The second theme concerned the experience of being discharged and the third theme sought to illuminate the experience of returning to everyday life after discharge. The last theme concerned the elderly patients’ experiences of receiving rehabilitation as part of their everyday lives after discharge. The interview guide was based on the aim of the study (theme two and three). No professional language was used in the interview guide or during the interview. The validity of the interview guide was strengthened through discussion with a senior researcher and through a single pilot interview, which led to minor revisions in the wording. Questions used in the interview guide are presented in Table 7.

Table 7: Interview guide Theme Interview questions At the hospital Please try to explain how you experienced being admitted to hospital. During your hospital stay, did anybody talk to you about how you manage different tasks at home? Discharge Please describe the discharge from hospital and how you experienced this. Getting home What was it like to come home again after hospital admission? What was important to you after you came home from the hospital? Please try to describe to me how you manage your everyday life at home. Rehabilitation How do you experience being offered to participate in rehabilitation?

In the process of collecting data, I sought to obtain rich descriptions with details, nuances and examples. After a short briefing, patients were invited to talk freely and in detail about their admission, discharge, and how they experienced returning to their everyday lives, and both positive and negative aspects were explored. The role as interviewer was to be a neutral facilitator so that the patients could account for their experiences as fully as possible. Prompts such as "Could you give an example of this" or "Could you elaborate on what you are telling me" were used to encourage the patients to describe more in detail how they felt and acted. This was done so I could get closer to understanding their individual experiences (144,145). Active listening and periods of silence were also used. All interviews were audiotaped and transcribed verbatim afterwards, which resulted in 202 pages of text.

Data analysis Malterud’s systematic text condensation which is a modification of Giorgi’s descriptive phenomenological method, was used in the analysis of the qualitative interviews (146,147). Malterud’s description provides a clear procedure for coding, decontextualisation and recontextualisation (146–148). Systematic text condensation is an explorative and descriptive method for thematic cross-case analysis. The method focused on patterns and variations in the data and identified what was meaningful to an individual patient and what was meaningful across several patients (146,147). An inductive or data-driven approach was

chosen in the analysis, as I wanted the aspects from the elderly patients’ experiences to shape the themes and codes, not theory or other preconceptions.

The method consists of the following steps, leading to a description of the patients' experiences: 1) Forming an overall impression: All of the interviews were listened to and transcripts were read as a whole several times to gain an overview of the total content. Then nine preliminary themes were identified. 2) Identifying and sorting meaning units: Meaning units containing information that related to the nine preliminary themes were identified and colour coded. 3) Condensation: Data were reduced and condensed into a decontextualised selection of meaning units and sorted into thematic sub-codes across the patients using a matrix. In the process, the focus was on maintaining the participants’ original terminology to describe the experiences as accurately as possible. 4) Synthesising the codes into descriptions: The condensed meaning units were synthesised into descriptions that related to each theme and subtheme. Meaningful quotations describing the content of the subthemes were added in the description. The quotations demonstrate both similarities and differences in how the participants experienced being discharged and returning to their everyday lives. In this step, the nine themes were reduced to four themes including subthemes.

Moving between the four steps was done iteratively, from the overall impression of all text to particular parts of the transcripts, identifying themes and subthemes of importance from the elderly patients’ perspectives (146,147). To maximise the validity of the analysis, all the identified themes and codes were first discussed with a senior researcher and then the final selection of themes was discussed with the whole project group. After the analysis, a retrospective check was performed to ensure that at least three of the elderly patients had added to each single code (146,147). This was done in order to ensure that the analysis was conducted as a cross-case analysis. The reporting of this study was presented in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) to ensure trustworthiness and transparency (149).

Ethical issues The studies in the PhD project were conducted in agreement with the principles of the World Medical Association of Helsinki (150). Conduction of study II required no ethical approval as it did not include any experimental interventions. The Regional Ethics Committee confirmed that approval of Study I in the PhD project was not required as the project was classified as a quality assurance project (J. nr.1-10-72-108-14). The National Board of Health gave permission to obtain health-related data on patients in the usual practice group in study I, as it was not possible to obtain their personal permission (J.nr. 3-3013-608/1/). Both studies were approved by the Danish Data Protection Agency (J.nr. 2012-41-0763). Handling and storage of data were in accordance with guidelines from the Danish Data Protection Agency and were kept confidential. When conducting qualitative interviews, there are some ethical considerations concerning the relation between the interviewer and the participant. As an interviewer, it is my responsibility not to manipulate the dialogue. Before each interview, I made the premise behind the interview clear for the elderly patient, and I was explicit about their rights during and after the interview (144).

5. Results The results in this section are presented in relation to each study, as each study has its own specific aim. Additional results and more detailed presentations are available in the appended papers.

Results study Ia: Description of the intervention Step 1: A large proportion of elderly patients who are readmitted after discharge from an ED have limitations in performing activities (34,38,39). Owing to the occupational therapy perspective of the PhD project, such limitations were chosen as the primary risk factor to address in the intervention. Another important factor associated with risk of readmission was identified as coherent discharge (46–48), which also was addressed in the intervention. The result of the needs assessment is presented in the logic model in Figure 2.

Underlying behavioural and environmental factors and determinants for the two risk factors were identified using the International Classification of Functioning, Disability and Health (ICF) Model of Human Occupation (MoHO) and informal consultation with occupational therapists and physiotherapists (11,151). The underlying internal determinants that influence a person’s performance of activities were identified primarily as decreased skills in performing activities and low coping ability. When a person experiences decreased skills, his or her way of performing activities may change in relation to efficiency, effort, safety and independence (74,75). Inappropriate design of the home was identified as an external determinant that could influence the environmental factor; “level of accessibility in the patient’s home” and thus identified as an important determinant in relation to performing activities (151). Lack of information exchange and collaboration in providing rehabilitation needs when a patient is transferred from the hospital to primary care were identified as external determinants that influences a coordinated discharge. Waiting time for rehabilitation in the municipality and lack of information provided for the patient were identified through informal consultations.

Figure 2. Logic model of the problem, factors and determinants in elderly patients (1). Determinants Underlying factors Risk factors Problem Internal determinants Decreased skills*

Severe disease

Comorbidity

Low coping ability*

High age

Demographics such as low education level and civil status as single Behavioural factors Lack of knowledge Decreased ability to # about access to perform activities rehabilitation* Decreased participation in social activities Lack of experience in relation to limitations*

Limitations in performing activities Readmission

External determinants Incoherent discharge Inappropriate design of Environmental factors the home* Poor accessibility in the # home Lack of information between hospital and Poor accessibility in the primary care* community

Lack of information to Poor coordination patients between hospital and primary sector regards Waiting time for rehabilitation# rehabilitation*

Lack of social network * Determinants influenced by the intervention

# Factors chosen as outcomes for behavior and environmental change

Based on the needs assessment, the goal of the intervention was to reduce the risk of readmission by:  Enhancing elderly patients’ performance of activities  Supporting a coherent discharge by coordinating elderly patients’ discharge and transfer of rehabilitation needs from the ED to primary care

Step 2: The logic model was followed by a description of the intervention outcomes in Step 2. Intervention outcomes were related to underlying behavioural and environmental factors, and they were selected based on considerations regarding their potential to influence risk factors and, thus, readmission. In addition, outcomes had to be both changeable and possible to address in the acute setting (1). The outcomes were: - Enhanced ability to perform activities - Enhanced accessibility in the home - Enhanced coordination between hospital and primary care

The chosen outcome ‘enhanced ability to perform activities’ was divided into five performance objectives, and the two chosen outcomes related to the environmental factors were divided into three performance objectives. Changes objectives were generated by combining the most important and changeable determinants (as identified in Step 1) with the specified performance objectives (1). The product of step 2 was a matrix of change objectives for personal and environmental determinants, i.e. the most immediate targets of the intervention (1) (See Paper I).

In Step 3, theory- and evidence-based methods and strategies were identified in the literature. Although literature searches revealed inconsistent results from interventions that aimed to reduce the risk of readmission in elderly patients, some trends were seen. The interventions that were beneficial in reducing risk of readmission included pre-discharge assessment, a discharge plan and post-discharge follow-up visits. These three components were all applied in the developed intervention. A pre-discharge assessment of the elderly patient’s performance of activities was chosen as the first intervention component as such an assessment is the first step in identifying a need (75). Assessment tests were selected based on their being performance-based generic tests that were validated for use on older people. A self-reported measure of activity performance was also included to capture the elderly patient's perspective on limitations in performing activities (see Table 8). The most frequently reported interventions aimed to enhance older peoples performance of activities that occupational therapists use, were found to be retraining of activities, skill development, task and environmental modifications, and the use of assistive devices (102,104,105,108,109). These intervention models were used in the third component, the

follow-up home visit. The evidence-based methods were supplemented with theoretically derived methods and practical strategies from the Behaviour Change Techniques taxonomy and MoHO (151,152). To coordinate the discharge and transfer of rehabilitation needs, a plan for information exchange and fast referral was described in collaboration with occupational therapists from the municipality (see Table 8)

Step 4 presents the final developed intervention. The Elderly Activity Performance (EAP) intervention was developed to achieve the goal of reducing risk of readmission by addressing two factors, performance of activities and coordination of discharge, including transfer of elderly patients’ rehabilitation needs. The intervention’s focus was on a pre-discharge assessment of each individual elderly patient's performance of activities, referral to rehabilitation in primary care and a follow-up home visit the day after discharge with the purpose of enabling the elderly patient to perform basic activities and start rehabilitation immediately. In Component 1, elderly patients’ were assessed with the Timed Up and GO (TUG) (153), 30s- Chair Stand Test (30s-CST) (154) and the Assessment of Motor and Process Skills (75). Patients’ with identified limitations in performing activities received a rehabilitation plan and referral to post-discharge rehabilitation in primary care (Component 2). Primary care was informed by telephone about the patients discharge, and referral of the patient to further rehabilitation was carried out the same day in order to start rehabilitation immediately after discharge. In addition, the patient received both oral and written information about further rehabilitation and the follow-up home visit the day after discharge. During the follow-up home visit, the occupational therapist encouraged the patient to perform basic activities and provided direct training on how a specific activity could be performed differently to enable the patient to perform the activity (1). The occupational therapist screened the home for safety risks and factors that potentially could limit the performance of activities by using a checklist. If limitations and/or risk factors for safety were identified, the occupational therapist initiated minor relevant modifications of the home environment, such as removing a rug, moving a chair, etc (2). The final developed intervention reflects the client-centred and problem-solving occupational therapy approach in which the rehabilitation plan and follow-up visit at home was tailored to the individual patient’s need. In practice, this meant that the rehabilitation plan was based on

the individual patient’s limitations in performing valued activities. Basic within-home activities of importance to the patient were addressed during the follow-up home visit.

Component 1 was provided for all patients. Based on the results in Component 1 (assessment of activity performance), patients with identified limitations when performing activities received Component 2 (rehabilitation plan) and Component 3 (follow-up visit at home). The content of the EAP intervention is provided in Table 8.

Table 8. Content of the components in the Elderly Activity Performance intervention Component Health Content professional/ setting Component 1 Occupational Assessing the patient’s performance of daily activities with the measures; therapists and Timed-Up and Go (72,153,155,156). physiotherapist / 30s-Chair Stand Test (154,157). the short-stay unit Assessment of Motor and Process Skills (75,76,158). at the ED Barthel-20 used as self-report by interview (159–161). Limitation in performing activities was determined using the following cut-off values: Time Up and Go > 12 seconds (155). Chair Stand Test < 8 times in 30 seconds (157). AMPS motor ability < 1.50 logits and process ability < 1.00 logits (75). Patients that scored under/above cut-off values in at least one test were offered component 2 and 3.

Component 2 Occupational A rehabilitation plan for patients with identified limitations in performing therapist/ the short- activities in component 1 was conducted. Primary care was informed by stay unit at the ED telephone about the patients discharge, and referral of the patient to further rehabilitation was carried out the same day in order to start rehabilitation immediately after discharge. In addition, the patient received both oral and written information about further rehabilitation and the follow-up visit (2).

Component 3 Occupational The occupational therapist who assessed the patient and defined the therapist from the rehabilitation plan visited the patient at home the day after discharge in short-stay unit/ in order to enhance the patient's performance of activities. An adaptive§ the patient’s home and/or an acquisitional# approach was used– depending on the patient’s limitations in performing activities (1). The occupational therapist screened the home for safety risks and factors that potentially could limit the performance of activities by using a checklist. If limitations and/or risk factors for safety were identified, the occupational therapist initiated minor relevant modifications of the home environment, such as removing a carpet, chair e.g. Moreover, the occupational therapist encouraged the patient to perform activities and provided direct training on how a specific activity could be performed differently to enable the patient to perform the activity. A checklist was used to guide the occupational therapist and enhance standardised procedures at the follow-up visit. §Adaptive approach refers to that the occupational therapist teaches the patient alternative or compensatory strategies or demonstrates the use of an assistive device in order to perform the activity independently. #Acquisitional approach refers to that the occupational therapist train the patient’s skills using graduated activities

Results study Ib: Outcome evaluation During the inclusion period, 945 patients were screened for eligibility. A total of 410 patients met the inclusion criteria; 35 patients declined to participate when asked for consent to participate in the intervention group. In all, 144 patients were allocated to the intervention group and 231 patients to the usual practice group, a total of 375 patients (2) (Please see the section for data analysis for power calculation). The enrolment of study participants is shown in Figure 3.

Figure 3. Flow-chart of the study population in study I (2).

Enrolment Patients fulfilling inclusion criteria (n=945)

Transferred (n=408) From nursing home (n=43) Terminal (n=9) Dementia (n=58) Not Danish speaking (n=17) Included patients Declined to participate (n=35) (n=375)

Allocated to intervention (n= 144) Allocation Allocated to usual practice (n=231)

Analysed (n= 144) Analysis Analysed (n= 231) Excluded from analysis (n=0) Excluded from analysis (n= 0)

Characteristics of the study participants: The sample consisted of 375 elderly patients discharged from a short-stay unit at the ED. At baseline, the EAP intervention group and the usual practice group appeared comparable concerning gender, comorbidity and marital status. Patients in the EAP intervention group were on average older than patients in the usual practice group (81 years vs. 78 years, p =

0.003), and they were admitted longer than patients in the usual practice group (22.6 hours vs. 19.7 hours, p = 0.002). Baseline characteristics of the study participants are presented in Table 9 (2).

Table 9. Baseline characteristics of the study participants (n=375) (2). EAP intervention Usual practice Test for (n = 144) (n = 231) difference Mean age, years (SD) 81 (7.9) 78 (8.6) p = 0.003 Female, n (%) 79 (55) 122 (53) p = 0.699 Marital status, n (%) p = 0.171 Married 56 (39) 99 (43) Widowed 48 (33) 68 (29) Divorced 33 (23) 41 (18) Single 7 (5) 23 (10) Comorbidity, n (%)* p = 0.183 Low: score 0–1 75 (52) 131 (57) Moderate: score 2–3 45 (31) 62 (27) High: score >4 24 (17) 38 (16) Hours of admission, median, (IQR) 22.6 (17.8;31.9) 19.7 (13.7;26.2) p = 0.002 * Charlson’s Comorbidity Index

Risk of readmission and mortality No differences between groups were found regarding the primary outcome readmission within 26 weeks. In all, 44% of the patients in the EAP intervention group and 42% of patients in the usual practice group were readmitted within 26 weeks, RD = 0.02, 95% CI (-0.08;012) and RR = 1.05, 95% CI (0.83;1.33) (2). No differences in 30 days readmission were found between the two groups. Eighteen per cent of the patients in the EAP intervention group and 23% in the usual practice group were readmitted, RD = -0.05, 95% CI (-0.13;0.03) and RR = 0.78, 95% CI (0.51;1.19) (2). Mortality 26 weeks after discharge was 10% in both groups (Table 10).

The within group analysis of the usual practice group revealed differences in marital status and length of admission comparing those admitted in day-time with those admitted during afternoon and evenings (2). Patients in the usual practice group that were included in daytime had longer admission time; 25.4 (21.1;46.1) hours versus 17.5 (10.1;23.0) hours than those patients admitted during afternoons and evening. Forty-seven per cent of the patients in

the usual practice group that were admitted in afternoons and evenings and 34% of the patients admitted in day-time were married (p = 0.044).

Adjusting for those factors that were different within the usual practice group in combination with the a priori confounders age, gender and comorbidity did not show any significant difference in either readmission within 26 weeks, readmission within 30 days or mortality (2).

Table 10. Comparison of risk of readmission and mortality for the study participants (n = 375) (2) Risk Difference (RD) Risk Ratio (RR)

EAP Usual Crude Adjusted* Crude Adjusted* intervention practice (95%CI) (95%CI) (95%CI) (95%CI) n = 144 n = 231 Readmission 64 (44) 99 (42) 0.02 (-0.08;0.12) 0.02 (-0.09;0.12) 1.05 (0.83;1.33) 1.07 (0.84;1.36) 26 weeks, n (%)

Readmission 25 (18) 55 (23) -0.05 (-0.13;0.03) -0.04 (-0.12;0.04) 0.78 (0.51;1.19) 0.83 (0.51;1.35) 30 days, n (%) Mortality 14 (10) 23 (10) -0.00 (-0.06;0.06) -0.01 (-0.09;0.8) 0.98 (0.52;1.83) 1.06 (0.68;1.66) 26 weeks, n (%) *Adjusted for age, gender, admission time, marital status and comorbidity measured with Charlson’s Comorbidity Index (CCI)

A total of 26 % of the patients in both the EAP intervention group and the usual practice group were readmitted once within 26 weeks. Eighteen per cent of patients in the EAP intervention group and 17% of patients in the usual practice group were readmitted two times or more within 26 weeks (2). Figure 4 shows the percentage distribution of readmissions within 26 weeks following discharge.

Figure 4. Bar plot of the percentage distribution of elderly patients readmitted within 26 weeks after discharge (n = 375). 30 25 20 15 10

5 Percentage distribution Percentage 0 1 2 3 4 5 6 7 Number of readmissions within 26 weeks EAP-intervention group Usual practice group

Analysis within the EAP intervention group Table 11 shows the distribution of the intervention components on patients in the intervention group. All patients in the intervention group were assessed with at least one of the performance-based assessments in component 1. Based on the results from that assessment, a total of 87 (60%) of the patients in the intervention group were referred to primary care rehabilitation. Of those, 69 (79%) patients received a follow-up visit by the occupational therapist the day after discharge (2).

Table 11: Intervention components in the EAP intervention group (n = 144) (2) Frequency of total (%) Component 1£ Assessment of limitations in performing activities 144 (100) Assessment with the TUG* 120 (83) Assessment with the 30s-CST# 126 (88) Assessment with the AMPS § 96 (67) Component 2: Rehabilitation plan 87 (60) Component 3: Follow-up visit 69 (48) £All patients in the intervention group were assessed with at least one of the performance-based measures in component 1 *Timed-up and go #30s-Chair Stand Test §Assessment of Motor and Process Skills

An exploratory analysis within the EAP intervention group showed a significant difference between patients who received all components and patients only receiving component 1. Fifty-one per cent of the patients receiving all components in the EAP intervention were readmitted within 26 weeks compared to 33% of the patients who only received component 1, RD = 0.18 (0.02;0.35) and RR = 1.55 (1.02;2.36). Regards risk of readmission within 30 days, 23% of patients receiving all components in the EAP intervention were readmitted, while 11% of the patients who only received component 1 were readmitted, RD = 0.12 (0.01;0.24) and RR = 2.18 (0.93;5.12) (Table 12).

Table 12. Risk of readmission within the EAP intervention group (n=144) (3) All components* Only component 1# Risk difference Risk Ratio n = 87 n = 57 (95%CI) (95%CI) Readmission 45 (51) 19 (33) 0.18 (0.02;0.35) 1.55 (1.02;2.36) 26 weeks, n (%)

Readmission 19 (23) 6 (11) 0.12 (0.01;0.24) 2.18 (0.93;5.12) 30 days, n (%) *All components: Assessment of the limitations in performing activities (component 1), rehabilitation plan (component 2) and follow-up visit at the patient’s home (component 3). # Component 1: assessment of limitations in performing activities.

Self-reported activity limitations Figure 5 describes self-reported limitations in performing activities measured with WHODAS 2.0 at baseline, 30 days and 26 weeks after discharge, within the EAP intervention group. The median summary score at baseline was 62 (IQR 48-86) (n = 142), at 30 days it was 61 (IQR 47-85) (n = 102), and at 26 weeks the median summary score was 49 (IQR 38-63) (n = 56). There was a tendency towards a lower disability score at 26 weeks than at baseline and 30 days after discharge

Figure 5. Self-reported limitations in performing activities within the EAP intervention measured with WHODAS 2.0

18 16

14 * 12 10 8 6

Domaine score Domaine 4 2 0 Cognition Mobility self-care Social Life activties Participation Baseline n=142 30 days n=102 26 weeks n=56

*Scores for the domains in WHODAS 2.0: Cognition = 0-30, Mobility = 0-25, Self-care = 0-20, Social = 0-25, Life activities = 0-20, Participation = 0-40. High score indicates severe disability

Results study II: Patients’ perspectives Patient characteristics Eleven elderly patients participated in individual interviews, three men and eight women, aged 65–86 years. Eight were living alone and five of the eleven elderly patients’ received support from primary care. Table 13 present characteristics of the participants.

Table 13: Characteristics of the participants (n = 11) Patient Gender Age Marital status Reason for Length of Support from admission admission primary care Anna Female 83 Living alone Back pain 2 days + Bo Male 70 Living alone Infection 1 day - Carla Female 86 Living alone Respiratory 2 days + Dorthe Female 76 Living with partner Neurological 1 day - Erik Male 65 Living alone Neurological 1 day + Frida Female 83 Living alone Infection 2 days - Grethe Female 73 Living alone Respiratory 1 day - Hanne Female 67 Living alone Heart problem 1 day + Iben Female 67 Living alone Infection 1 day - Jette Female 76 Living with partner Neurological 1 day + Kurt Male 76 Living with partner Neurological 1 day -

Four themes emerged during the qualitative analysis; “The importance of being involved and listened to during admission”, The importance of being prepared for discharge”, Pain and fatigue limited performance of activities” and “Frustrations and concerns about lack of clarification”. The four themes are presented in more details in the appended Paper III. In this section, results from the analysis will be presented in two categories; the first will describe the elderly patients’ experiences of being discharged, the second category will describe the elderly patients’ experiences of returning to everyday life after discharge from a short-stay unit at the ED (Table 14). A synthesis of factors of importance for the elderly patients’ experiences of being discharged and returning to their everyday lives is presented at the end of the result section.

Table 14. Themes and categories identified in the qualitative analysis Themes Categories The importance of being involved and listened to during admission Experiences of being discharged The importance of being prepared for discharge

Pain and fatigue limited performance of activities Experiences of returning to everyday life after discharge Frustrations and concerns about lack of clarification

Experiences of being discharged To be involved in decision-making and listened to during admission were important factors for the elderly patients and the experience of not being listened to could make them feel uninvolved in the discharge process. They found that although some physicians were good at informing about further actions and/or examinations, the physicians were sometimes too busy to ask for the patient’s perspective. Some patients expressed that they were too tired to ask the physicians questions, which could lead to several unresolved issues in relation to discharge. Being prepared before discharge was also of importance. The elderly patients’ were all discharged shortly after admission (1–2 days), which for several of them came as a surprise. Not everyone agreed with the decision about being discharged, and some felt that they had not been involved in the decision. The elderly patients’ experienced that they were discharged home with ongoing health problems and limitations in performing activities that

should have been resolved. Some of them experienced their admission to hospital as a waste of time.

Another factor that was central to the elderly patients’ experiences of the discharge was feeling secure about returning home. The elderly patients’ who lived with a spouse experienced a sense of security, as there was someone to care for them after discharge. Information about whether there was going to be further examinations, rehabilitation, or care after the discharge was deemed important in relation to the quality of the elderly patients’ discharge. Some of the elderly patients experienced that they got the information they needed in relation to their discharge, while others experienced that they did not. To receive written information was of importance, as it was considered helpful to have something to turn to when feeling unsecure about the situation.

Experiences of returning to everyday life after discharge The elderly patients’ experienced their everyday lives as being marked by fatigue, lack of energy and pain, all of which affected their performance of activities. Pain was experienced as a limitation in performing activities. For some of the elderly, it was difficult to be as mobile as they had been previously, which meant that they did not get outside their home as often as before admission. Fatigue and lack of energy made it difficult to perform their usual activities as they had before admission, which led to a feeling of irritation about not being able to manage activities at the moment. Sometimes, the elderly patients’ were able to adapt to this by dividing a specific activity into smaller tasks that could be carried out over several days or by using assistive devices. In other cases, resting in the middle of the day could help provide the energy needed to get through the afternoon and evening. Expectations regarding rehabilitation after discharge were mostly positive. The elderly patients wanted to be able to perform activities as they used to before they were admitted to the ED. For participants who did not receive a clear diagnosis during admission, thoughts of further rehabilitation were difficult to manage. They were concerned about their health condition and how they would be able to handle further examinations. Lack of clarification as to what led to their admission, also created speculations that affected their everyday lives. Concerns about what caused the admission meant that some speculated on how their lives would look in the long term. The elderly patients were also concerned about whether they would be able to perform their activities in the long term.

Factors of importance for elderly patients The analysis of elderly patients' experiences of their discharge and returning to everyday lives revealed different factors of importance for ensuring a coherent discharge. The identified factors are presented in Table 14.

Table 14. Factors of importance for elderly patients discharge and their returning to everyday lives Factors Of importance for the discharge Being prepared before discharge Feeling secure about returning home Receiving needed information Being involved and listened to Of importance for the everyday life after Reduced performance of activities discharge Speculations and lack of clarification about health condition

Summary of results An intervention was developed and evaluated in Study I, with the aim of reduce the risk of readmission in elderly patients discharged from a short-stay unit at the ED. The developed EAP intervention addressed the two risk factors for readmission: limitations in performing activities and an incoherent discharge for elderly patients. The EAP intervention was not effective in reducing the risk of readmission in the intervention group compared to usual practice. The within group analysis of patients in the EAP intervention group revealed that elderly patients identified as having limitations in performing activities were at higher risk of readmission within 26 weeks after discharge than patients with no identified activity limitations. In the qualitative interviews in Study II, the elderly patients expressed that their everyday lives after discharge were influenced by pain, fatigue and lack of energy which limited their performance of activities. Speculations concerning their health condition and the future were also present in their everyday lives. The qualitative interviews also revealed that factors such as receiving information, feeling secure and being involved and prepared are important for elderly patients when they are discharged from a short-stay unit at the ED.

6. Discussion In the first part of this section, a discussion of the main results is provided in the context of existing literature. This is followed by methodological considerations of strengths and limitations of importance to the internal validity in the overall multi-method design and two specific studies. In addition, the studies external validity is discussed.

Discussion of the main results The results from the studies conducted in this PhD project contribute with new knowledge to inform future practice and research regarding the discharge of elderly patients from a short- stay unit at an ED. It was expected that a short-term intervention that combined identification of elderly patients with limitations in performing activities with a coordinated discharge and a referral to rehabilitation immediately post-discharge had the potential to reduce the risk of readmission. However, the EAP intervention was not effective in reducing risk of readmission and thus did not improve current practice in discharging elderly patients. However, the intervention was capable of identifying patients with limitations in performing activities who were at high risk of readmission. The findings from the qualitative interviews revealed that factors such as receiving information, feeling secure and being involved and prepared are important for elderly patients when they are discharged from a short-stay unit at the ED.

Effectiveness of the EAP intervention The outcome evaluation of Study I showed that the intervention was not effective compared with usual practice in reducing risk of readmission within 26 weeks after discharge. Thus, the study’s results contribute to the divergent evidence concerning reducing the risk of readmission in elderly patients discharged from a short-stay unit at an ED. As described in the background section of this dissertation, other studies that aimed to reduce the risk of readmission in elderly patients discharged from an ED also reported zero effect (88,91,93,95). However, other studies showed some effectiveness regarding readmission (87,89,90,92,94). Common to them is that the interventions are rather comprehensive in addressing different risk factors, and in three of five studies, follow-up visits in patients’ homes were part of the intervention. A study from 2004 with 739 elderly patients discharged from an ED reported that a comprehensive geriatric assessment was effective in reducing risk

of readmission after 30 days and 18 months compared with usual practice (87). In addition, a comprehensive discharge planning intervention was reported to be effective in reducing risk of readmission in a study from 2011 with 656 elderly patients (92). Another study, including 128 elderly patients, reported a significant reduction in ED readmission for the intervention group that received comprehensive nursing and physiotherapy assessment, exercise programmes, home visits and follow-up phone calls (89). Home-visits were also a part of the intervention in a study conducted in another Danish healthcare setting (94). This trial included 1.330 elderly patients and found that a home visit by a geriatrician and nurse the day after discharge was effective in reducing readmission within 30 days (94). These studies’ results seem to indicate that the components discharge planning and home visits are effective in interventions that aim to reduce the risk of readmission. Thus, we included these two components in the EAP intervention. More emphasis could have been put on other factors, but it was an important premise of the EAP intervention that it should be delivered as an addition to usual practice and should be feasible to implement in the existing healthcare system.

An explanation for the non-effectiveness of the EAP intervention may be related to the intensity and duration of the intervention. Within the intervention group limitations in performing activities showed no changes in performance of activities from baseline to 26 weeks for patients in the EAP intervention group. This may indicate that the intervention was not intensive enough to change this intermediate outcome. Enhancing a person’s performance of activities often involves a change in behaviour of the person such as change or adaption in performance skills (151). To ensure that a change is adopted and becomes part of a daily routine, a certain amount of intervention exposure is required (151). Studies that include occupational therapy interventions, either as mono-disciplinary or part of multidisciplinary approaches, have shown positive results in enhancing performance of activities in elderly patients when interventions were conducted over a longer period and with several sessions (98,102,104,107,110). However, a comparison between these studies and the EAP intervention should be done with caution, as none of these occupational therapy interventions aimed to reduce the risk of readmission for elderly patients discharged from a short-stay unit at the ED. In addition, the studies included a different study population, namely, community dwelling older people who had not been hospitalised (98,101). Although the EAP intervention may have been too short or too low in intensity, some studies showed

that short-term interventions with low intensity can produce effects related to both performance of activities (107,109) and the final goal, reducing risk of readmission (90,94). The EAP intervention was conducted in collaboration with primary care which was responsible for fast referral to further rehabilitation. Type and duration of further rehabilitation was decided by responsible healthcare professionals from the municipality and could include reablement, individual or group-based occupational therapy and/or physiotherapy. In a Danish healthcare setting, the municipalities are obligated by law to initiate post-discharge rehabilitation if the patient is referred to rehabilitation in primary care from the hospital. Thus, we relied on the primary care sector to initiate rehabilitation in relation to elderly patients’ needs as specified in their rehabilitation plan. However, we did not measure whether this was implemented as intended. A recent published study (162) conducted in a similar healthcare setting in Denmark showed that although an agreement was made in relation to immediate post-discharge rehabilitation, only 48% of patients in the intervention group received the rehabilitation they were assigned to post-discharge.

Risk factors addressed in the EAP intervention To our knowledge, the developed EAP intervention in Study I is the first to involve a specific focus on enhancing elderly patients’ performance of activities to reduce their risk of readmission. Although the EAP-intervention was not effective, the results from the exploratory within group analysis in Study Ib revealed an association between limitations in performing activities and risk of readmission in the intervention group. Patients who only received Component 1 were less likely to be readmitted than those who received all intervention components. This may be due to patient characteristics, as patients who only received Component 1 did not have limitations in performing activities; thus, they did not need a rehabilitation plan or further post-discharge rehabilitation in the municipality. Along with the body of scientific knowledge about risk factors for readmission and the results from Study II, it enables us to confirm that addressing limitations in performing activities as part of the EAP intervention was a well-chosen element to include in the discharge of elderly patients (33,35). Another risk factor addressed concerning readmission was incoherent discharge of the elderly patients, and that factor was addressed through Component 2. Determinants viewed as negatively influencing the underlying factor (coordination) of a coherent discharge were waiting time for rehabilitation, lack of shared information between the hospital and

municipality and lack of information given to patients. The design of the outcome evaluation in Study I did not allow for direct measurement of whether the intervention changed this intermediate outcome. However, in Study II, qualitative interviews with some of the elderly patients from the EAP intervention group were conducted to explore their experiences of being discharged. The interviews revealed that factors such as receiving written information about future examinations, rehabilitation or care, feeling secure and being involved and prepared were important to elderly patients when they were discharged from a short-stay unit at the ED. These findings correspond with findings from other studies based on interviews with elderly patients discharged from hospital (58–60). A qualitative study in which 26 elderly patients and their relatives were interviewed, describes different areas in which it was considered important for elderly patients to have certain relevant information and arrangements made to feel prepared for discharge. The areas were 1) information on care issues such as health status, treatment and continuing care, 2) activity performance such as support at home and/or training and 3) knowing whom to contact if immediate help is needed. Feeling prepared was considered of great importance to these elderly patients and their relatives and influenced their experiences with discharge quality. All three areas were also important in their everyday lives after discharge (59). Concerning the factor “being prepared for discharge” which the elderly patients identified as important, it is a great challenge in the acute setting in which patients may only be admitted for up to 48 hours. Elderly patients may not have experienced this kind of hospital admission before, and may not be able to modify their expectations to the reality adequately. They may be surprised that they were discharged so soon, even before they felt better. This amplifies their need to feel that the health professionals know what they are doing, and it places a great responsibility on the health professionals to live up to this expectation. Although the qualitative study conducted in this PhD project revealed findings that resembled those of other studies, it differs in that it interviewed elderly patients discharged from a short- stay unit at an ED which has very short admission times (one to two days). Thus, the circumstances may be different when compared with patients hospitalised for up to a week or more. Short admission time combined with limited preparation for elderly patients’ discharge, may influence coordination between healthcare sectors. A focus on identifying these factors seems to be an important step in the process of improving discharge and avoiding serious adverse events, including readmission.

Identifying patients at risk of readmission The within-group analysis of patients in the EAP intervention group revealed that 60% of the patients had limitations in performing activities when they were discharged from the short- stay unit at the ED, thus 40% did not experience activity limitations and had no need for Components 2 and 3 in the intervention. This high proportion of patients with no identified limitations in performing activities may have contributed to the non-effectiveness of the EAP intervention as it may have diluted possible effects. To achieve a more homogenous sample in which all patients are identified with limitations in performing activities, the use of a screening instrument to identify and select patients at high risk may have been relevant prior to inclusion. In the literature, some studies noted that using a screening instrument to identify high risk patients frequently was beneficial in reported outcomes such as readmission and nursing home admissions, compared with interventions with no risk stratification (9,84). One screening instrument that can be used to identify patients at high risk and that is translated and validated in a Danish context is the Identification of Seniors at Risk (ISAR) questionnaire (163,164), which comprised six questions with dichotomised answers (yes/no) and a sum-score (range of 0–6), with a score of 2 or more used as a cut-off for high risk. However, the evidence concerning the use of ISAR is divergent. Studies found that using ISAR as a screening instrument to identify high risk patients prior to interventions may be beneficial, but that it did not reduce risk of readmission (95,165). We chose to include comprehensive performance-based assessment of limitations in performing activities as part of the EAP intervention (Component 1). This choice was based on the rationale that the use of a few self-reported questions would not be enough to identify elderly patients with limitations in performing activities, as elderly patients acutely admitted may not yet be aware of possible limitations. Also, results from performance-based measures of elderly patients’ performance of activities were used in the rehabilitation plan (Component 2) to provide high quality information delivery to primary care. The use of three performance-based measures in Component 1 may be viewed as too comprehensive for use in elderly patients at a short-stay unit at an ED, in that not all patients in the EAP intervention group wanted or were able to perform all three tests in Study Ib. By using both the TUG and 30s-CST to assess basic mobility, the possibility that the patients could perform at least one of the tests was high. Both the TUG and 30s-CST are simple to administer and have been validated for use with populations of older community-dwelling people (71,72,157,166). However, the tests’ validity and usefulness in acute settings are still

sparse. A study from 2017 (167) found that concurrent validity of the 30s-CST compared with the de Morton Mobility Index was acceptable when used in a sample of 156 elderly patients at a short stay unit at the ED. In another ED setting with 911 elderly patients, the TUG was found to be useful in identifying patients at risk of functional decline after discharge (168). A significant association between TUG score and risk of functional decline within three and six months after discharge was reported (168). Although some aspects of validity had been examined, it would be relevant to further examine different aspects of the tests’ validity when used with elderly patients in acute settings. AMPS was included in the test-battery as it provides a more comprehensive picture of the quality of activity performance. As described in the background section of this dissertation, when assessing performance of activities, it is important to include quality parameters and not just determine whether the person can/cannot perform (AMPS). Assessing the quality of how the specific task or activity is performed is an important part of the OT assessment approach, and the AMPS seems to be the only standardised and validated test to use (75). The AMPS test results identified motor and process skills that needed to be improved or compensated for in the individual or the environment to ensure safe, independent and efficient performance of activities, without increased physical effort. The results from the AMPS test were used not only to identify limitations in performing activities, but also in the rehabilitation plan to describe the elderly patients’ actual activity performance and recommend which kind of rehabilitation should be provided to the patient after discharge. Another important aspect of the AMPS test is the interview in which the patient in collaboration with the occupational therapist determines the person’s need and determines what performance of activities the person reports as problems. From an occupational therapy and client-centred perspective, the patients perception of his or her performance of activities is of great importance when assessing limitations in performing activities (169). Combining performance-based and self-reported approaches may be especially relevant when identifying elderly patients limitations in performing activities. Studies that have compared the two approaches have reported that performance-based and self-reported measures seem to provide different information and they recommend a combination of both approaches (65,68–70). In our study, the use of three performance-based measures, including the interview as part of the AMPS test, identified patients with limitations in performing activities and who were at higher risk of readmission. Whether a less comprehensive assessment to the same extent

would be able to identify patients with limitations in performing activities is unknown and requires further research.

Everyday life after discharge Some of the elderly patients’ who participated in Study II experienced unresolved health problems and limitations in their performance of activities after discharge. Those findings resembled findings from another qualitative study conducted among elderly patients discharged from an acute medical unit and their care givers (170). The consequences of limitations in performing activities and how they are handled may have a major impact on an individual's everyday life. Some elderly patients in Study II were able to handle their limitations in performing activities by using adaptation strategies, such as dividing activities into smaller tasks or otherwise changing their performance. These findings are recognised in other qualitative studies (56,171,172). In a qualitative study from 2015, elderly patients and their caregivers found adaption to everyday life after discharge to be challenging but also of great importance (56). A qualitative study of 15 elderly patients revealed that they adopted different adaptation strategies in their everyday lives to avoid negative experiences due to their health conditions (172). Not all the elderly patients in Study II were capable of using adaptation strategies, which for some resulted in abstaining from performing those activities when limitations were experienced. Continuing to perform activities that are meaningful generally is considered important for the well-being of older people (173–175). Therefore, elderly patients may benefit from support and guidance in how to use effective adaptation strategies to enable them to perform meaningful activities after discharge. For some of the elderly patients in Study II, their everyday lives were influenced by thoughts about their un-clarified health conditions as well as concerns for the future. They speculated on whether they would be able to perform their usual activities in the long run or if they would experience a loss of activities. Our findings on elderly patients’ concerns are in accordance with the findings of another study in which elderly patients were concerned about how to handle their life situation after being discharged (59). In our study, elderly patients with diagnoses that were un-clarified were particularly concerned about the impact of their health conditions on their everyday lives. These findings are important to consider in clinical practice. The occupational therapist and physiotherapist who deliver rehabilitation in the

municipality should address such concerns and individual strategies to deal with present and future problems should be strengthened.

Methodological considerations The overall aim of this PhD project warrants the use of both quantitative and qualitative approaches to provide experimental results, as well as produce a deeper understanding of elderly patients' experiences. A multi-method design including both qualitative and quantitative methodologies is considered a strength in the PhD project as the different methodologies and findings complement each other in addressing the overall aim. The choice of timing in the studies in the multi-method design provided advantages as well as disadvantages. The outcome evaluation of the effectiveness of the EAP intervention in Study Ib and the qualitative interviews in Study II were conducted concurrently, and thus the results of one study could not influence the design of the other. Conducting qualitative interviews with elderly patients before developing and evaluating the EAP intervention may have been beneficial in strengthening the components that were addressed in the intervention. For example, the interviews stressed the importance of being well-prepared for discharge, and elderly patients’ involvement in the study’s development phase might have resulted in a greater focus on this. Patient and public involvement (PPI) is highly recommended today when an intervention is developed, tested, evaluated and implemented to enhance a study’s relevance (119). We considered it a limitation that no patients were involved in the development phase, but we also viewed it as a strength that the qualitative interviews were conducted with patients who had received the intervention, as they had useful, first-hand experiences with the discharge process. Although the specific aim of Study II was not to evaluate patients’ experiences with the intervention, the inductive approach allowed us to examine how the intervention during their hospital stay and post-discharge rehabilitation was experienced in their everyday lives.

Study Ia In describing the development and content of the EAP intervention, we used the Intervention Mapping approach (117), which provides a methodological step-by step procedure. It is widely used in the development of health promotion programmes and when describing the intervention such an approach is considered a strength as it emphasises the transparency of the development phase (117). Multiple methods such as systematic literature searches,

consultations with clinical health-professionals, establishing a steering group and conducting a logic model of the problem were used during the development phase to strengthen the EAP intervention. Further along in the development phase, the Intervention Mapping approach enabled us to ensure that those methods and practical applications that were chosen for the three components in the EAP intervention were based on either theory or evidence-based literature. Following the Intervention Mapping approach in describing the intervention allowed us to be transparent in reporting its underlying theory, thereby enhancing the possibility of replicating the intervention, as recommended by the Medical Research Council in its guidance on the development and evaluation of complex interventions (54). The use of a logic model to link the goal of the intervention with risk factors and their underlying factors and determinants allowed us to define what should change to receive the goal of reducing risk of readmission. However, we do not know whether the intervention actually was capable of enhancing the performance of activities and supporting a coherent discharge. Change in self-reported performance of activities was only possible to measure within the intervention group, as patients in the usual practice group were followed only with registry-based data. A single group pre-post design is not optimal for evaluating the effectiveness of an intervention, however it can provide preliminary results. In our study, the within-group description of activity performance showed no changes for patients in the EAP intervention group. Whether a coherent discharge was achieved could not be measured either. The lack of a clear definition of what characterises a coherent discharge makes it difficult to measure. From the literature, coordination was identified as an underlying factor of importance for a coherent discharge, but although we chose coordination of the discharge as a specific outcome (Step 2) we did not operationalise or measure it. Hence, we do not know whether the discharge of patients in the intervention group was well-coordinated nor do we know whether a well- coordinated discharge leads to a coherent discharge. This is considered a study weakness. If we had used the Intervention Mapping approach prospectively we would have placed a greater focus on how to operationalise and measure the two intermediate outcomes or the more specific outcomes related to the underlying factors. This way, we could have gained deeper insight into whether a disconnect existed in the linked factors and outcomes in the logic model, and important insights into why the intervention was not successful in reducing risk of readmission could have been gained.

Study Ib Evaluation and study design The evaluation of the effectiveness of the intervention was conducted as an outcome evaluation. Outcome evaluations of experimental trials measure the impact of the intervention in the target population but fail to elucidate the reasons why the intervention was a success or failure (119). A process evaluation conducted alongside the outcome evaluation would have provided deeper insights into intervention fidelity (176,177). Also, implementation of the post-discharge intervention in the municipality was not monitored adequately. This was not planned, and a process evaluation was impossible to conduct afterward due to the registry practice in the municipality. Consequently, we do not know whether the therapists in the municipality delivered the post-discharge rehabilitation as intended. This preferable could have been examined further by registration of dose (time), frequency and the kind of therapy that the therapist offered in the municipality after the follow-up visit (119).

To evaluate the effectiveness of the EAP intervention, a pragmatic non-randomised, quasi- experimental superiority trial was conducted, comparing an intervention and a control group. Multitudes of factors constrain conduct during clinical trials within the acute care setting. Explanatory trials tend to be tightly controlled and include homogeneous patient groups and both factors are challenged in acute settings with a high flow of patients. Pragmatic trials are designed primarily to determine intervention’s effects under usual conditions (178). The quasi-experimental design was found feasible to evaluate the effectiveness of the intervention in a real-world clinical setting, although it is placed lower than the randomised controlled trial in the evidence hierarchy (54,118).

Study participants The allocation of patients resulted in two groups that seemed quite similar at baseline on several factors, but allocation bias may have occurred due to the non-randomised allocation and concealment of patients. Patients allocated to the intervention group were included during mornings, while patients assigned to the usual-practice group were included during both daytime and after hours. We consider this to be a systematic difference that may have introduced bias, and the differences between the two groups in baseline characteristics support this. Admission time was significantly different between the two groups, in which

patients in the intervention group were admitted three hours longer than patients in the usual practice group. One reason for this could be related to the health status of patients in the intervention group. Although no significant differences existed between the two groups in relation to comorbidity, patients in the intervention group were significantly older than patients in the usual practice group and increased age is associated with disabilities (179). Therefore, the higher age in the intervention group may be associated with a higher need for a more comprehensive assessment which is more time demanding. Another possibility of the difference in length of admission is related to the organisational structure of short-stay units. In our clinical practice, elderly patients admitted during evening or overnight hours usually are discharged first the following day, not at night. In the analyses, we adjusted for factors that we a priori had considered potentially could confound the results, as well as for baseline differences, such as age and admission time, by performing multivariate analyses – the recommended method to use after a study has been conducted (180). Although the results revealed no differences between the adjusted and unadjusted results, we cannot rule out the possibility that other unknown factors might have caused allocation bias. Whichever direction the possible allocation bias may have steered the results seems impossible to establish, as allocation bias can steer the results in both directions inconsistently (181). A systematic review from 2016 (182) that aimed to study the mechanisms and direction of allocation bias found that such bias in many trials will exaggerate the estimated intervention effect (e.g., overestimate the effect). For studies that do not report the effects from the intervention, the impact of allocation bias seems less important to the results. If we use the knowledge from the systematic review to our study (Study Ib), which found no tendency toward a between-group difference, this may suggest that the impact of possible allocation bias would only be minor. The within group analysis of the usual practice group revealed differences in the subgroups (daytime vs. afternoon and evening admissions) in relation to marital status and admission time. This was handled by adjusting for the influence of those two factors in the sub- analyses, and this did not alter the overall findings of the study. As a method for preventing potential confounding when using a non-randomised design, we could have used restriction in the selection of participants (180). However, the use of restriction in form of several exclusion criteria may very well have hampered the external validity of the findings and made the trial less pragmatic (178).

Intervention provided The occupational therapists and physiotherapists delivering the intervention at the ED’s short-stay unit participated in a one-day course during which they were introduced to the EAP intervention’s components. Afterward, they participated in a two-week programme in which they practised delivering the assessments in Component 1 over a two-week period. No tests of inter-rater reliability between the two physiotherapists who delivered the TUG and 30s-CST were performed. Ideally, such tests should have been carried out to examine whether discrepancies existed in the results. As far as the AMPS used by the occupational therapist, all three recently (within six months) had been calibrated in relation to rater reliability. To enhance the intervention’s fidelity, weekly meetings were organised between participating research therapists and the project leader. At the meetings, the therapists had the opportunity to report and discuss problems related to delivering the intervention as intended. Some discrepancies were reported, including that the AMPS could be difficult to deliver due to both time and the physical environment at the short-stay unit at the ED. In such cases in which the AMPS was not possible to conduct, a rehabilitation plan was drawn up based only on the results from the TUG and 30s-CST. Due to the nature of the study, we were unable to blind patients or health professionals at the short-stay unit regarding who received the intervention. To reduce the possibility of contamination, the occupational therapists and physiotherapists who delivered the EAP intervention were not allowed to assess or prepare the discharge of patients in the usual practice group. Thus, none of the patients in the usual practice group received follow-up visits after discharge, although some may have, via self-referral, received some kind of municipal or private rehabilitation and/or home care after discharge. This is a consequence of our pragmatic approach and should not be viewed as a study weakness.

Outcome measures Readmission within 26 weeks after discharge was chosen to be primary outcome as the overall aim was to reduce elderly patients' risk of readmission. Should the intervention be able to affect the risk, a rather long follow-up period was considered necessary. Conversely, it would be possible that a potential effect would phase out during a long follow-up period. Thus, risk of readmission within 30 days was chosen as a secondary outcome.

Several important methodological concerns were related to the choice of readmission as an indicator of the delivered intervention’s quality or effectiveness (183). Readmission may not necessarily indicate poor quality of care and treatment at the hospital, but rather may be influenced by the care that patients receive after discharge. Readmission also may indicate a patient and/or relative’s proper reaction to symptoms and disease progression which necessitates a readmission. In such cases, readmission can serve to improve health status. All- cause readmission was chosen although it is subject to influences from factors that may be non-modifiable, such as disease progression. Instead, we could have focused only on potentially preventable readmissions, as others recommended (183,184). However, the definition of a potentially preventable readmission is, not well-determined (184). An element to consider when using readmission as an outcome is that comparing rates or risk of readmission between different healthcare systems and countries may be problematic due to the ill-defined concept of readmission (183). In our study, we found readmission to be a relevant primary outcome, as the goal of the EAP intervention was to reduce the risk of readmission.

National registers were used for the collection of data, which is considered a strength. Data in these registers are recorded prospectively and they provide a high level of completeness (185,186). Thus, the use of register-based data ensured a complete follow-up (100 %) on all outcomes measured. The power calculation revealed that a sample of 304 patients, 152 in each arm, was required allowing for a 10% drop out. During the recruitment period, we were able to include 144 patients in the intervention group. Therefore the study may have been underpowered. However, the use of a pseudo-value approach, accounting for death as a competing risk by estimating the cumulative incidence function, meant that it was possible to include those who actually died during the 26 week follow-up period in the analysis, thereby eliminating drop out. Patients who died during the study period (10%) remained in the risk set until their competing event (death), thereby contributed with risk time. A revised power calculation that omitted a dropout percentage shows that a sample of 274 patients with 137 in each arm should be enough to detect a reduction in risk of readmission a 16 percent point – given that the intervention had succeeded. Thus, we do not think that the statistical results were underpowered.

Study II The stuy findings’ trustworthiness was established with a well-described method for analysing data and a clear description of the whole research process to ensure transparency. A detailed description of the study setting and participating elderly patients was provided to be clear about findings’ the transferability to other contexts. The inspiration from a phenomenological approach allowed me to pursue what was important for the elderly patients, rather than seeking answers to predefined questions. The use of a semi-structured interview guide during the interviews served as a frame to ensure that all themes important to answering the research question were approached while simultaneously gaving me the opportunity to discover new and important themes. However, the approach posed challenges related to how the elderly patients expressed themselves, as their ability to communicate and describe their experiences varied. Broad variations in elderly patients gender, age, diagnosis, marital status and home care use, were achieved to provided nuanced insights into the elderly patients’ experiences, and extensive interviews were conducted. This resulted in rich and varied data that provide insights into the elderly patients’ experiences of being discharged and returning to their everyday lives, in accordance with our strategy, in which we relied on rich and varied data rather than seeking data saturation. The term “data saturation” is generally discussed in the qualitative methodological literature as a criterion for discontinuing data collection (142,187). The term indicates that the researcher continues collecting data until nothing new is apparent (187). Originally, saturation was used in grounded theory but today, it is used across different qualitative approaches (142,187). Despite the fact, that it has been adopted widely in qualitative literature, research on whether it is consistent in relation to different approaches or how to achieve it, interestingly is lacking. In our study, the goal was not data saturation, as we wanted to explore elderly patients’ experiences of being discharged and returning to their everyday lives to identify factors of importance that could contribute with new knowledge to guide future discharge of elderly patients, rather than build a comprehensive theory (188).

External validity Elderly patients with multiple health conditions were represented in all three studies, which is a strength in term of external validity, as they present a general picture of elderly patients discharged from short-stay units at EDs. However, the elderly patients who participated in

this PhD project cannot be expected to represent the population of interest entirely, as most of them specifically were invited and agreed to participate (189). The participating elderly patients were 65 years or older, spoke Danish, were residents in the municipality of Aarhus and were discharged directly from a short-stay unit at the ED to their homes. As inclusion criteria were used in recruiting patients, the results cannot be generalised directly to the entire elderly population. On the other hand, it can be inferred that the results from Study I are valid for elderly patients admitted on weekdays and discharged from a short-stay unit at an ED in a Danish health-care setting. As a large variation exists between how the health-care systems are organised and financed in different countries, the results of the studies in this PhD project may be difficult to generalise beyond Denmark. In Study II, the voluntary participation might have yielded a sample that held strong views about the discharge process, which may affect the findings’ transferability. Recruiting elderly patients who had been involved in a clinical trial is relevant in relation to transferability. The results from Study II cannot be transferred to all elderly patients, but can be viewed as an important knowledge contribution to developing future interventions.

7. Conclusion The overall research aim was to improve and inform current practice regarding the discharge of elderly patients from a short-stay unit at an ED in order to reduce their risk of readmission. Two studies, each with its own specific aim, were conducted to achieve this. Across the included studies, the findings in this PhD project contributed with new knowledge from the intervention and from the qualitative interviews, which can contribute to further research and development in this important area.

In Study I, an intervention that emphasised on enhancing performance of activities and a coherent discharge from a short-stay unit at the ED for elderly patients was developed, described systematically and evaluated in a clinical setting. The intervention did not prove to be effective, as it did not lead to a reduction in the primary outcome, risk of readmission compared with usual practice, nor did any of the secondary outcomes differ between the intervention and the usual practice group. Therefore, implementation of the EAP intervention cannot be recommended in its current form. Although the intervention did not prove effective in reducing risk of readmission, the initial assessment in Component 1 revealed that 60% of the elderly patients in the intervention group had limitations in performing activities and a need for further rehabilitation after discharge. Thus, the assessment in Component 1 seems to be capable of identifying elderly patients at high risk of readmission. It also revealed that the elderly patients’ identified as having activity limitations were at a significantly higher risk of readmission than patients with no identified limitations. This supports our underlying assumptions about the association between limitations in performing activities and risk of readmission.

Study II provided in-depth knowledge about how elderly patients experienced being discharged and returning to everyday life from a short-stay unit at an ED. Receiving information, being prepared and involved, and feeling secure about returning home were identified as factors of importance for the elderly patients during discharge. Factors such as limitations in performing activities and speculations concerning health condition and the future were present in the elderly patients’ everyday lives after discharge.

8. Clinical implications and future research In this PhD project, an intervention that aimed to reduce the risk of readmission was developed and evaluated experimentally along with qualitative interviews with some of the elderly patients who received the intervention. Based on the outcome evaluation of the EAP intervention conducted in Study I, the intervention in the applied form cannot be recommended as a means to reduce risk of readmission in elderly patients discharged from a short-stay unit at an ED. Nevertheless, important lessons were learned from both the outcome evaluation of the intervention and the elderly patients’ perspectives, and some recommendations for clinical practice and future research can be inferred from the present PhD project

Although the EAP intervention did not prove to be effective in this trial, the results indicate that a large number of elderly patients discharged from a short-stay unit at the ED has activity limitations which are associated with a higher risk of readmission. The assessment in Component 1 in this study was able to identify 60% as having activity limitations. This calls for increasing efforts to identify elderly patients with such limitations, but we do not know whether other tests would be more sensitive in identifying patients. This should be examined in future studies.

The role of occupational therapists in a short-stay unit at the ED is to identify patients with activity limitations and coordinate their discharge and referral to post-discharge rehabilitation in primary care, which was the focus of this project’s intervention. However, further research on the effectiveness of such interventions is required in combination with a more comprehensive post-discharge rehabilitation intervention that emphasises reducing the risk of preventable readmission in high risk elderly patients discharged from short-stay units at the EDs. Alongside the outcome evaluation of the effectiveness of such intervention, a process evaluation should be conducted to determine whether the intervention is delivered as intended.

Findings from the qualitative interviews suggest that elderly patients wish to be more prepared and involved within their discharge and that some expressed concerns and experienced activity limitations after their discharge. This indicates that health-care professionals should more thoroughly inform elderly patients during their discharge about

their situation including the consequences of their condition and their influence on performing activities in everyday life. This illustrates a need for further research to examine how this can be addressed in clinical practice. In such research, the population of interest should be involved during the development phase.

9. References

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10. Papers

Paper I Development of a complex intervention aimed at reducing the risk of readmission of elderly patients discharged from the emergency department using the Intervention mapping protocol. Published in: BMC Health Services Research 2018;18:588 (1).

Paper II Effectiveness of the "Elderly Activity Performance Intervention" on elderly patients discharge from a short stay unit at the Emergency Department – A quasi-experimental trial. Published in: Clinical Interventions in Aging 2018;13:737-747 (2).

Paper III Returning to everyday life after discharge from a short stay unit at the Emergency Department– a qualitative study of elderly patients’ experiences. Submitted to: International Journal of Qualitative Studies in Health & Well-being, June 2018 (in review) (3).

Paper I Nielsen et al. BMC Health Services Research (2018) 18:588 https://doi.org/10.1186/s12913-018-3391-4

RESEARCH ARTICLE Open Access Development of a complex intervention aimed at reducing the risk of readmission of elderly patients discharged from the emergency department using the intervention mapping protocol Louise Moeldrup Nielsen1,2* , Thomas Maribo3,4, Hans Kirkegaard5, Kirsten Shultz Petersen6 and Lisa Gregersen Oestergaard1,3,7

Abstract Background: Limitations in performing daily activities and a incoherent discharge are risk factors for readmission of elderly patients after discharge from the emergency department. This paper describes the development and design of a complex intervention whose aim was to reduce the risk of readmission of elderly patients discharged from the emergency department. Methods: The intervention was described using the Intervention Mapping approach. In step 1, a needs assessment was conducted to analyse causes of readmission. In steps 2 and 3, expected improvements in terms of intervention outcomes, performance objectives and change objectives were specified and linked to selected theory- and evidence-based methods. In step 4, the specific intervention components were developed; and in step 5, an implementation plan was described. Finally, in step 6, a plan for evaluating the effectiveness of the intervention was described. The intervention was informed by input from a literature search, informal interviews and an expert steering group. Results: A three-phased theory- and evidence-based intervention was developed. The intervention consisted of 1) assessment of performance of daily activities, 2) defining a rehabilitation plan and 3) a follow-up home visit the day after discharge with focus on enhancing the patients’ performance of daily activities. Conclusion: The intervention mapping protocol was found to be a useful method to describe and systemize this theory- and evidence-based intervention. Keywords: Intervention, Functioning, ADL, Emergency department, Acute care, Occupational therapy, ICF

Background are readmitted during the first 30 days after their discharge Readmission to hospital or Emergency Department (ED) is [4–6]. These readmissions have considerable consequences a common and important healthcare problem among eld- for both the elderly patients and society in general. Re- erly patients in many parts of the world [1–3]. In Western admission is associated with an increase in elderly patients’ countries, up to 20% of elderly patients admitted to an ED risk of infections, medical complications and limitations in performing daily activities [7, 8]. Different factors such as age, comorbidity, medication, diagnoses and activity limita- * Correspondence: [email protected]; [email protected] ’ 1Department of Physiotherapy and Occupational Therapy, Aarhus University tions contribute to elderly patients risk of readmission and Hospital, Aarhus, Denmark mortality [2, 7]. A large proportion of elderly patients 2Department of Occupational Therapy, VIA University College, Aarhus, admitted to the ED are discharged directly to their home Denmark ’ Full list of author information is available at the end of the article [9]. Transferring the patients care and rehabilitation at

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Nielsen et al. BMC Health Services Research (2018) 18:588 Page 2 of 11

discharge from the ED to primary care is a challenge and In step three, theory-and evidence-based methods and involves a risk of lost information, which may influence the strategies are selected which then inform the intervention patients’ experiences of the discharge and their further re- developed in step four. Steps five and six describe the plan habilitation [10]. for implementation and evaluation, respectively [24]. Interventions that are aimed at preventing readmission in elderly patients discharged from the ED have been Step 1: Logic model of the problem previously evaluated, but there is a lack of consensus re- A steering group, a project group and a reference group garding which initiatives are the most effective [9–15]. A were established with the aim of bringing expertise to systematic review from 2005, revealed that different the project. A steering group counting 11 members was home-based interventions improved the elderly patients established with experts from both hospital and primary performance of daily activities after their discharged care. Five of these experts were also part of the project from the ED [10]. However, despite this, the home-based group, including the project leader. The project group interventions did not seem to have any effect on the risk was responsible for planning, implementing and evaluat- of readmission. A systematic review from 2015 evaluated ing the intervention. A reference group with physiothera- the effect of transitional interventions for elderly pa- pists (PT) and occupational therapists (OT) from the ED tients discharged from the ED [9]. It found no effect on contributed with information about the clinical context. either readmission or mortality. A systematic review In the developing phase, two meetings with the steering from 2012 evaluated the effect of care coordination after group and approximately five meeting with the reference ED discharge and concluded that the majority of studies group were conducted. All decisions from those meetings evaluating such initiatives reported that they were effect- were based on discussion. If any disagreement should ive in reducing readmission in the elderly [13]. However, occur, the project leader had the final decision. the evidence on how to prevent readmission of elderly Then a needs assessment was performed based on patients discharged from the ED is inconclusive and findings from the literature, and informal interviews conflicting and, as several studies have highlighted, qual- with health professionals from the hospital and primary ity studies of the effectiveness of transitional interven- care were undertaken. The needs assessment was struc- tions for the elderly are needed [9, 10, 13]. Limitations tured using a logic model that defined phase 1) the in performing daily activities have been identified as a problem; phase 2) risk factors; phase 3) underlying be- predictor for readmission and mortality in elderly pa- havioural and environmental factors that could affect the tients [1, 2, 16, 17]. However, to our knowledge, only a risk factors; and phase 4) determinants for the behav- few studies have evaluated the effectiveness of enhancing ioural and environmental factors [24]. After conducting the elderly patients’ performance of daily activities in the needs assessment, the context for the intervention order to prevent their readmission and reduce their was described based on input from clinical experts from mortality [18–20]. None of these interventions was the steering group, reference group and the literature. short-term or conducted in an acute hospital setting. Finally, the goals for the intervention were set. We therefore found it relevant to develop and design a short-term intervention that focused on enhancing the elderly patients performance of daily activities and to en- Step 2: Outcomes and objectives sure a coherent discharge from ashort-stayunitattheED. To outline the goals for the intervention, we identified The purpose of this paper is to describe the develop- overall outcomes for behavioural and environmental ment of a complex intervention that is aimed at reducing change after discussions in the project group and the refer- the risk of readmission of elderly patients discharged from ence group. The overall outcomes were then divided into a short-stay unit at the ED. separate performance objectives that explicitly described what should happen in order to achieve the outcome. The Methods most important internal (relates to the person) and external There is growing understanding that the development (relates to the environment) determinants, identified in step and design of interventions should be more transparent 1, were then combined with the specified performance [21–23]. The description of the present intervention objectives to formulate change objectives. These change followed the steps of the Intervention Mapping (IM) objectives were actions that specified what would change in protocol for developing health promotion programmes the determinants as a result of the intervention and were [24]. IM provides a methodological, step-by-step proced- required in order to achieve the performance objectives ure in an iterative process. The six steps in the protocol and the overall outcome. The performance objectives and include several tasks that describe the development change objectives were then discussed in the project group process. The first two steps involve the description of a before matrices for behavioural and environmental changes needs assessment and the objectives of the intervention. were constructed. Nielsen et al. BMC Health Services Research (2018) 18:588 Page 3 of 11

Step 3: Selecting methods and strategies feasibility of the intervention and to examine how the A search of the literature was undertaken to identify theory- intervention could be delivered in practice. The pilot and evidence-based methods that relate to the change study was evaluated by registration of how many pa- objectives in step 2 and that could influence change tients it was possible to include, how many refused to in the determinants and outcomes. participate, time used for component 1 and registration First, we searched for tests to assess limitations in eld- of the possibility of referral of rehabilitation plan and erly patients’ performance of daily activities (please see follow-up visits. Additional file 1). Tests were selected on the basis that they were performance-based generic tests that were val- Results idated for the elderly population, and that were simple The results of the development process are presented to administer in a clinical setting. Next, we searched for following the six steps as described in the method sec- studies that examined the effect of interventions that tion. Steps 1 to 3 address the development of the inter- aimed at reducing the risk of readmission (please see vention, step 4 presents the final intervention and steps Additional file 2). The identified methods from the lit- 5 to 6 describe the implementation and evaluation plan. erature were then linked to the change objectives in the form of practical strategies suitable for implementation in the concrete setting. Decisions about methods and Step 1: Logic model of the problem suitable strategies were made in conjunction with the In the needs assessment, we defined the overall problem reference group. as high risk of hospital readmission in the elderly after their discharge from an short stay unit at the ED. This is Step 4: Developing intervention components a well-described problem in the literature [1, 7, 16, 25] Key components of the intervention were selected based and is supported by experiences of the health profes- on the identified criteria of importance, feasibility and sionals involved in developing the intervention. The out- resource constraints. The components were described come of the needs assessment is presented in the logic and practical applications for use in the different compo- model in Fig. 1. nents were constructed. A description for performing Factors associated with the risk of readmission of elderly the components in the intervention was developed and patients were identified from the literature. Limitations in component 1 was pretested with a similar population of performing daily activities was chosen as the most signifi- elderly patients admitted to the ED. The tests in compo- cant risk factor, as a large proportion of elderly patients re- nent 1, identified in step 3, were pretested in a two admitted has limitations in performing daily activities and weeks period, in order to examine whether the tests because it is a factor that is possible to address in an acute were possible to use in an acute setting. The pretest was setting with a short-time frame. In the elderly, both the done by the therapists responsible for delivering the perceived illness and hospitalisation involve a risk of limi- intervention. During the pretest, the therapist received tations in performing daily activities [26–30]. Another im- supervision from the project leader in order to ensure portant factor associated with risk of readmission was a that the test was used as described. incoherent discharge [31, 32]. After ranking the risk factors, underlying behavioural and environmental factors Step 5: Implementation plan and determinants for the two risk factors were identified A plan for ensuring the implementation of the interven- using the International Classification of Functioning, tion was conducted in cooperation with the reference Disability and Health (ICF) and the Model of Human group. Potential problems and barriers associated with Occupation (MoHO) [33–35]. The focal points chosen for implementation of the intervention were discussed with further development were the behavioural factor ‘decreased the reference group. Also, a plan for educating health ability to perform daily activities’ and the two environmen- professionals performing the intervention was devised. tal factors, ‘poor accessibility in the home’ and ‘poor coordination between hospital and primary care’ (see Fig. 1). The Step 6: Evaluation plan internal determinants that influence a person’s ability to In step 6, we developed a plan for evaluating the effect- perform daily activities were identified as decreased skills in iveness of the intervention and for examining the elderly performing daily activities. When a person experiences de- patients’ experiences of being discharged from the ED creased skills, his or her way of performing daily activities and their return to everyday lives. A protocol was drawn may change in relation to efficiency, effort, safety and inde- up that described the design of the study, aim, hypoth- pendence [36]. In addition, the environment can influence esis, recruitment plan and the methods used to evaluate the elderly individual’s ability to perform daily activities by the intervention. We also conducted a pilot study de- either enabling or inhibiting performance. Accessibility in signed as a randomized controlled trial to test the the patient’s home and in the community was identified as Nielsen et al. BMC Health Services Research (2018) 18:588 Page 4 of 11

Fig. 1 Overview of the problem, factors and determinants in elderly patients with activity limitations important environmental factors in relation to performing on their basis of considerations regarding their potential daily activities [35]. to influence readmission, as described in the literature. On the basis of informal interviews with health profes- Furthermore, the outcome had to be both changeable sionals, the determinant related to the identified inco- and possible to coordinate in the acute setting. The out- herent discharge from the short stay unit at the ED was comes were: defined as lack of information exchange between health professionals from the hospital to primary care. Waiting Increase the patient’s ability to perform daily activities time for rehabilitation and lack of information provided Increased accessibility in the home to the patient were also identified as determinants for a Enhanced coordination between hospital and incoherent discharge. primary care. Based on the needs assessment, the goals of the intervention were to reduce the risk of readmission by: The outcome ‘Increasing the patient’s ability to perform daily activities’ was divided into five performance objectives, Enhancing the patient’s performance of daily and the two outcomes that related to the environment were activities divided into three performance objectives (see Table 1). Ensuring a coherent discharge Then, the most important and changeable determinants (as identified in step 1) were combined with the specified per- Step 2: Outcomes and objectives formance objectives in the form of change objectives in a Specific outcomes related to behavioural and environ- matrix. The matrix for the behavioural and environmental mental factors were stated. The outcomes were selected outcomes is presented in Table 1. Nielsen et al. BMC Health Services Research (2018) 18:588 Page 5 of 11

Table 1 Matrix of performance objectives, change objectives and determinants in elderly patients with limitations in the ability to perform daily activities Time/setting Performance objectives, Internal patients related determinants Performance skills Coping ability Lack of knowledge Lack of experience about access in relation to to rehabilitation current situation Day 0/ At the ED Decide to participate Receive relevant Recognize that in assessment of information about the ability to activity limitations the assessment perform activities have changed due to illness Day 0/ At the ED Participate in performance- Agree to be Experience based assessment assessed in relation possible change to perform activities in performance of daily activities Day 0/ At the ED Decide to participate in Agree to participate Achieve and consider Recognize that further rehabilitation information about the ability to opportunities for perform daily further rehabilitation activities have changed Day 1 and after/ Perform the training Train to perform Train in how to ask for Patient home activities in a assistance and/or help different way Consider information Train motor and about possible strategies process skills

Time/setting Performance objectives, External determinants staff related Lack of information Waiting time for Inappropriate design of the between hospital rehabilitation patient’s home and primary care after discharge Day 0/ At the ED Inform primary care about OT prescribe Fast referral of the patient being discharged rehabilitation plan patient and plans for further OT at the ED contacts rehabilitation therapists from primary care Day 0/ At the ED Change visitation Make directly contact procedure for patients to therapists from referral primary care Day 1/ Patient home Access accessibility Screen the patients in the patients home home in relation to safety risk when performing daily activities Day 1/ Patient home Make minor necessary Remove carpets changes in patients home Arrange furniture

Step 3: Selecting methods and strategies skills training leads to increased ability to perform daily In order to address the determinants and performance activities [38, 39]. The evidence-based methods were then objectives specified in step 2, suitable theoretical and supplemented with theoretically derived methods and evidence-based methods were identified in the literature. practical strategies from the Behaviour Change Techniques Based on our search of the literature, we found the most taxonomy [40]andMoHO[35]. Table 2 shows the frequently reported approaches used to increase the per- identified methods and practical strategies applied for each formance of daily activities to be skill development, task determinant that related to each performance objective. and environmental modification, and the use of assisted devices [20, 37, 38]. We found sparse evidence on the Step 4: Developing intervention components following environmental outcomes: safety and prevention, The practical strategies were combined to produce the use of adaptive equipment, environmental modification and intervention which consisted of three different compo- assisted devices [20, 37]. There seems to be evidence that nents (Fig. 2). Nielsen et al. BMC Health Services Research (2018) 18:588 Page 6 of 11

Table 2 Determinants, methods and practical applications used to realize change objective in elderly patients with activity limitations discharge from the emergency department Determinanta Methodsb Practical applications/Strategiesc Performance skills Assessment OT and PT at the ED use performance-based tests to assess the patients ability to perform daily activities Information OT at the ED gives oral and written information about test result Tailoring OT at the ED match the further intervention to the patients need of rehabilitation Acquisitional approach Skills training with the OT after discharge using graduated daily activities until the goal of activity is achieved Restorative approach Skills training with the OT after discharge using graduated daily activities until the goal of body function is achieved Adaptive approach OT from primary care teach alternative or compensatory strategies and teach in use of assistive devises after discharge Coping ability Feedback OT gives the patient information regarding the extent to which they accomplish learning and performance Knowledge about access Information The patient receive oral and written information about opportunities to rehabilitation from the OT at the ED Consulting OT from the ED advise the patient about opportunities Lack of experience in relation Direct experience The patient performs daily activities both at the ED and at the home to new situation visit the day after discharge Inappropriate design of Adaptive approach The OT from the ED advices on minor home modification at the home the home visit the day after discharge Lack of information between Information OT uses results from the tests in the patients rehabilitation plan hospital and primary care Intergroup contact Telephone meetings between OT/PT’s at the ED and form primary care to coordinated discharge and further rehabilitation Waiting time for rehabilitation Change visitation process The project leader conducts meetings with chief of rehabilitation from primary care Start training immediately The OT from the ED conducts home visit with training the day after discharge after discharge aDeterminants identified in the needs assessment step 1 bMethods identified in the literature that could influence change in the determinants cPractical applications/strategies describes how the method practically could be delivered

Component 1 involved an assessment, lasting up to modifications of the home environment. Moreover, the two hours, of individual patients’ performance of daily OT encouraged the patient to perform daily activities activities at the ED. Three performance-based measures and provided direct training on how a specific activity Timed-Up and Go, 30s-Chair Stand Test and the As- could be performed differently to enable the patient to sessment of Motor and Process Skills were selected as perform the activity. To ensure standardised procedures the test battery and performed by OTs and PTs [41–45]. in the intervention, a checklist was developed to guide A rehabilitation plan was then conducted for patients the OT at the home visit. Additionally, these visits aimed with identified activity limitations in component 2. After to ensure a coherent post-discharge period. discharge, the patient’s rehabilitation plan was used as a referral to further rehabilitation in primary care. Primary Step 5: Implementation plan care practitioners were informed about the patient’s dis- As part of the developed plan for implementation, the charge, and referral of the patient to further rehabilita- PTs and OTs delivering the intervention participated in tion was carried out the same day with the aim of a one-day training course that introduced the compo- starting rehabilitation immediately after discharge. nents in the intervention. After this introduction, the In component 3, the OT who assessed the patient and therapists received supervision and feedback on how defined the rehabilitation plan visited the patient at they delivered the intervention during the first weeks of home the day after discharge in order to enhance the pa- implementation. During the recruitment period, weekly tient’s independence in performing daily activities. The meetings were organised between the participating staff OT used an adaptive and/or an acquisitional approach and the project leader with the aim of discussing and [36]. The OT screened the home for safety risks and fac- solving potential problems. Meetings between healthcare tors that could potentially limit the individual’s perform- managers from primary care and the project leader were ance of daily activities. If limitations and/or risk factors held to discuss implementation of the rehabilitation for safety were identified, the OT provided advice on plans. At each primary care unit (eight) in the catchment Nielsen et al. BMC Health Services Research (2018) 18:588 Page 7 of 11

Fig. 2 Overview of the intervention components in the Elderly Activity Performance Intervention areas, a contact person (PT or OT) was appointed to the To test the acceptability of the intervention, recruit- study in order to ensure early initiation of the rehabilita- ment and randomization procedures before conducting tion plan. These contact people participated in a day a large scale study, we made a pilot study designed as a course that introduced them to the components of the randomised controlled trial. The study included 52 pa- intervention. Meetings with PTs and OTs from primary tients allocated to the intervention (n = 24) and the usual care who refer patients to further rehabilitation were held practice group (n = 28). The pilot study revealed that it with the aim of discussing how quick referrals could be was difficult to include patients as 67% of the eligible pa- conducted to minimise waiting time for patients. tients refused to participate. One of the main reasons for patients to refuse was that they, becauce of the randomisation procedures, had to agree to participate before Step 6: Evaluation plan knowing which group they would be assigned to. The An evaluation of the intervention will be conducted in evaluation from the pilot study also revealed that the order to evaluate the following aims: intervention was feasible to deliver and the design of the intervention therefore was not changed. 1. The effectiveness of the intervention with respect A quasi-experimental study with an intervention and a to readmission of elderly patients discharged control group will be conducted (Clinicaltrial.gov, from the ED NCT02078466). Inclusion criteria are the following: age 2. The cost-effectiveness of the intervention 65+, residency in a larger city in Denmark, admission at 3. Change in activity performance for patients in the a short-stay unit at the ED at a university hospital for intervention group medical reasons with the expectation of being directly 4. The elderly patient’sexperienceofbeing discharged home. Exclusion criteria are patients with discharged and returning to everyday life after an terminal illness, dementia, not speaking Danish or trans- acute admission ferral to another hospital department. Due to limited Nielsen et al. BMC Health Services Research (2018) 18:588 Page 8 of 11

resources and time, it will be possible to include and allo- during admission and at both 30 days and 26 weeks after cate up to two patients in the intervention group per day, discharge [47–50]. Monday - Friday. Each weekday at 8.00 am, a research ther- Elderly patients’ experiences of being discharged from apist will review all patients admitted in the last 24 h and ED and returning to everyday life will be examined in a screened for eligibility. If more than two patients are eli- qualitative study (aim 4). Individual interviews with 10 gible, allocation will based on the date of birth so that pa- patients who received the intervention will be con- tients born closest to the first day of a month (e.g. March ducted. The interviews will be analysed from a phenom- 1st) will be allocated to the intervention group. Patients not enological descriptive viewpoint, using systematic text included in the intervention group will be allocated to usual condensation. Purposive sampling of patients will be practice group. In addition, patients admitted after 8.00 am used to ensure variety in diagnosis, age, gender, material meeting the inclusion criteria and discharged out of hours status and support from primary care, as this could con- (afternoons and evenings) will be allocated to the usual tribute to the richness of data [51]. In accordance with a practice group. phenomenological approach, we intend to rely on The effectiveness of the intervention (aim 1) will be in-depth and rich data rather than the number of partic- analysed by comparing the intervention group with the ipants and the goal is to achieve data that are detailed, usual practice group in relation to readmission, mortality nuanced and of sufficient quality rather than seek data and contacts to general practitioners, emergency phys- saturation [51]. ician and the ED. The primary outcome is allcause readmission within 26 weeks registered in the National Discussion Patient Register. A follow-up time of 26 weeks is chosen This paper describes the development and planned as it is considered appropriate for enhancing elderly pa- evaluation of a complex intervention aimed at reducing tients performance of daily activities [1]. The secondary the risk of readmission of elderly patients following a outcomes are mortality and number of contacts to gen- stay at the ED. The development followed the six steps eral practitioners, an emergency physician and the ED in the IM protocol [24]. within 26 weeks. Readmission within 30 days is also Using an IM approach in developing interventions has measured as a secondary outcome. Based on the litera- several strengths. Multiple methods, such as interviews, ture, we assume that the intervention can reduce the a literature search and involving an expert steering risk of readmission within 26 weeks from 37 to 21% group helped to define the problem and identify [46]. Power analysis revealed that the sample size should methods used to target it. The use of IM during the consist of 152 patients in each group, assuming that 10% process ensured that the intervention was systematically of the participants are lost to follow-up. This implies described and based on available evidence and theory. that a total of 304 patients will be needed to detect a risk The logic model in step 1 enables project planners to be difference of 16 percentage point regarding readmission specific about the problem and the underlying determi- with a two-sided significance level of 5% and a power of nants and to decide what should change as a result of 80%. Patients in both the intervention group and the the intervention. usual practice group will receive standard treatment in As on of the goals for the intervention, we chose to relation to their medical conditions; the intervention focus on enhancing elderly patients’ performance of group will receive the developed intervention. daily activities, as limitations in performing daily activ- Alongside the quasi-experimental study, we will make a ities have been identified as high-risk factors for re- economic evaluation (aim 2) as a cost-effectiveness ana- admission [1, 3, 7, 16, 17]. Despite the fact that lysis with the main parameters being readmission and limitations in performing daily activities is documented mortality. A healthcare viewpoint will be taken to estimate as a risk factor for readmission, this focus is seldom used the cost of all activities and ressource use related to the in interventions aimed at reducing the risk of readmis- patients’ rehabilitation. National registers will be used to sion in elderly patients. Frequently, interventions that estimate resource use in primary and secondary healthcare aim to reduce readmission in elderly patients include sectors. The cost of the intervention will be based on medical treatment, discharge planning and coordination micro-costing. To assess cost-effectiveness, the incremen- of care [12, 51–54]. Some studies within comprehensive tal cost-effectiveness ratio will be calculated. geriatric care have developed interventions aimed at Change in performance of daily activities (aim 3) will improving geriatric care patients’ performance of daily be examined within the intervention group. Data regard- activities. However, the descriptions of these interven- ing self-reported limitations in performing daily activities tions are insufficient, making it impossible to replicate measured with Barthel-20 and WHODAS 2.0 and them [11, 14, 15, 55]. health-related quality of life measured with EQ-5D will Although IM was found to be a useful and systematic be collected using a structured interview questionnaire method for describing the intervention, it was also Nielsen et al. BMC Health Services Research (2018) 18:588 Page 9 of 11

time-consuming. Developing matrices with performance Additional files objectives (step 2) was particularly time-consuming because of the lack of clear guidance on how to select both Additional file 1: Keywords and search string. (PDF 27 kb) the performance objectives and the most important deter- Additional file 2: Keywords and search string for effectivenss studies. minants. We chose pragmatically the determinants that (PDF 29 kb) had the greatest influence on readmission and were considered changeable and feasible to address in the setting. Abbreviations In the implementation plan, we chose a different strat- CGC: Comprehensive geriatric care; ED: Emergency Department; ICF: International classification of functioning, disability and health; egy than recommended by the IM protocol. Instead of IM: Intervention mapping; MoHO: Model of human occupation; constructing a matrix with performance objectives and MRC: Medical research council; OT: Occupational therapist; change objectives for the use of the intervention, we PT: Physiotherapist found it less time-consuming and more feasible to list the performance objectives. Acknowledgements We acknowledge participants from the steering group and from the Patient representatives were not included in the devel- reference group. opment of the intervention. Involvement of users is generally recognized as important when improving the quality Funding of healthcare services. Lack of user involvement is therefor The research was founded by Tryg Foundation, Foundation of Public Health ’ considered as a limitation in the development of the in the Middle and Aase and Ejnar Danielsen s foundation. intervention. Although it was time-consuming to follow the IM Availability of data and materials All data generated or analysed during this study are included in this protocol, doing so allowed us to describ and design an published article. intervention that was focused, theory-based and partly evidence-based. Our intention with this paper is to de- Authors’ contributions scribe how we developed the intervention using different LMN completed the intervention mapping process with feedback from LGOE, conducted the literature review and drafted the manuscript. LGOE, HK, methods, and to describe the intervention with sufficient KSP and TM participated in the intervention mapping process and helped to detail and transparency so that replication is possible. draft the manuscript. All authors read and approved the manuscript. This is in line with the recommendation from the Medical Research Council (MRC) that reporting the Ethics approval and consent to participate underlying theory, methods and strategies is valuable be- Evaluation of the effectiveness of the intervention is approved by the Danish Data Protection Agency (J.nr. 2012–41-0763) and by the National Health Board cause it enhances the possibility of replicating effective (3–3013-608/1/). The regional ethics committee confirmed that approval of the interventions [21]. study was not required because biomedical experiments were not included (J. Further studies will evaluate the effectiveness of the de- nr.1–10–72-108-14). All patients in the intervention group will receive written and verbal information about the conditions of their participation and sign veloped intervention and will be conducted according to informed consent prior to inclusion. The study is registered in Clinicaltrial.gov MRC guidance on how to develop and evaluate complex (NCT02078466). The pilot study was approved by the Danish Data Protection interventions [21]. This means that besides the systematic Agency (J.nr. 2012–41-0763). All of the participants in the pilotstudy received written and verbal information about the conditions of their participation and development process and pilot testing of the intervention, signed informed consent prior to inclusion. the evaluation will include an effectiveness evaluation, an ’ economic evaluation and a description of the patients Consent for publication perspective. The evaluation of effectiveness will contribute Not applicable. with knowledge on strategies for reducing the risk of readmission in elderly patients with limitations in perform- Competing interests ing daily activities and is an important part of building The authors declare that they have no competing interests. evidence-based practice in rehabilitation. Publisher’sNote Conclusion Springer Nature remains neutral with regard to jurisdictional claims in The present paper describes the development and design published maps and institutional affiliations. of a complex intervention using the IM protocol. The Author details intervention is aimed at reducing the risk of readmission 1Department of Physiotherapy and Occupational Therapy, Aarhus University 2 of elderly patients discharged from the ED. Despite the Hospital, Aarhus, Denmark. Department of Occupational Therapy, VIA University College, Aarhus, Denmark. 3Department of Public Health, Aarhus time-consuming process, the IM protocol was found to University, Aarhus, Denmark. 4DEFACTUM, Central Denmark Region , Aarhus, be a useful method with which to guide the development Denmark. 5Research Center for Emergency Medicine, Aarhus University 6 of the complex intervention. It allowed us to develop a Hospital, Aarhus, Denmark. Department of Health Science and Technolog, Aalborg University, Aalborg, Denmark. 7Centre of Research in Rehabilitation theory- and evidence-based intervention that can be de- (CORIR) Department of Clinical Medicin, Aarhus University and Aarhus livered in a clinical ED context. University Hospital, Aarhus, Denmark. Nielsen et al. BMC Health Services Research (2018) 18:588 Page 10 of 11

Received: 23 May 2017 Accepted: 15 July 2018 difficulties in older adults: results from a randomized trial. J Am Geriatr Soc. 2009;57:476–81. 21. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M, et al. Developing and evaluating complex interventions: the new Medical References Research Council guidance. BMJ. 2008;337:a1655. 1. Comette P, D'Hoore W, Malhomme B, Van Pee D, Meert P, Swine C. 22. Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, et al. Differential risk factors for early and later hospital readmission of older Better reporting of interventions: template for intervention description and patients. Aging Clin Exp Res. 2005;17:322–8. replication (TIDieR) checklist and guide. BMJ. 2014;348:g1687. 2. Greysen SR, Stijacic Cenzer I, Auerbach AD, Covinsky KE. Functional 23. Schulz KF, Altman DG, Moher D, CONSORT Group. CONSORT 2010 impairment and hospital readmission in Medicare seniors. 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Effect of short-term hospitalization 015–0055-7. on functional capacity in patients not restricted to bed. Am J Phys Med 8. Aminzadeh F, Dalziel WB. Older adults in the emergency department: a Rehabil. 2007;86:455–62. systematic review of patterns of use, adverse outcomes, and effectiveness 30. Zisberg A, Shadmi E, Sinoff G, Gur-Yaish N, Srulovici E, Admi H. Low mobility of interventions. Ann Emerg Med. 2002;39:238–47. during hospitalization and functional decline in older adults. J Am Geriatr 9. Lowthian JA, McGinnes RA, Brand CA, Barker AL, Cameron PA. Discharging Soc. 2011;59:266–73. older patients from the emergency department effectively: a systematic 31. Krevers B, Narvanen AL, Oberg B. Patient evaluation of the care and review and meta-analysis. Age Ageing. 2015;44:761–70. rehabilitation process in geriatric hospital care. Disabil Rehabil. 2002;24:482–91. 10. Hastings SN, Heflin MT. A systematic review of interventions to improve 32. Slatyer S, Toye C, Popescu A, Young J, Matthews A, Hill A, et al. Early re- outcomes for elders discharged from the emergency department. Acad presentation to hospital after discharge from an acute medical unit: Emerg Med. 2005;12:978–86. perspectives of older patients, their family caregivers and health 11. Caplan GA, Williams AJ, Daly B, Abraham K. A randomized, controlled trial of professionals. J Clin Nurs. 2013;22:445–55. comprehensive geriatric assessment and multidisciplinary intervention after 33. World Health Organization. International classification of functioning, discharge of elderly from the emergency department--the DEED II study. J disability and Health-ICF. Genève: World Health Organization; 2001. Am Geriatr Soc. 2004;52:1417–23. 34. Gladman JR. The international classification of functioning, disability and 12. Cunliffe AL, Gladman JR, Husbands SL, Miller P, Dewey ME, Harwood RH. health and its value to rehabilitation and geriatric medicine. J Chin Med Sooner and healthier: a randomised controlled trial and interview study of Assoc. 2008;71:275–8. an early discharge rehabilitation service for older people. Age Ageing. 2004; 35. Kielhofner G. Model of human occupation: theory and application. 4th ed. 33:246–52. Philadelphia: Lippincott Williams & Wilkins; 2008. 13. Katz EB, Carrier ER, Umscheid CA, Pines JM. Comparative effectiveness of 36. Fisher AG. Occupational therapy intervention process model: three star care coordination interventions in the emergency department: a systematic press, Inc; 2009. review. Ann Emerg Med. 2012;60:12–23. 37. Petersson I, Lilja M, Hammel J, Kottorp A. Impact of home modification 14. Legrain S, Tubach F, Bonnet-Zamponi D, Lemaire A, Aquino JP, Paillaud E, et services on ability in everyday life for people ageing with disabilities. J al. A new multimodal geriatric discharge-planning intervention to prevent Rehabil Med. 2008;40:253–60. emergency visits and rehospitalizations of older adults: the optimization of 38. Steultjens EM, Dekker J, Bouter LM, Jellema S, Bakker EB, van den Ende CH. medication in AGEd multicenter randomized controlled trial. J Am Geriatr Occupational therapy for community dwelling elderly people: a systematic Soc. 2011;59:2017–28. review. Age Ageing. 2004;33:453–60. 15. Mion LC, Palmer RM, Meldon SW, Bass DM, Singer ME, Payne SM, et al. Case 39. De Vriendt P, Peersman W, Florus A, Verbeke M, Van de Velde D. Improving finding and referral model for emergency department elders: a randomized health related quality of life and independence in community dwelling frail clinical trial. Ann Emerg Med. 2003;41:57–68. older adults through a client-Centred and activity-oriented program. A 16. Campbell SE, Seymour DG, Primrose WR, ACMEPLUS Project. A systematic pragmatic randomized controlled trial. J Nutr Health Aging. 2016;20:35–40. literature review of factors affecting outcome in older medical patients 40. Michie S, Richardson M, Johnston M, Abraham C, Francis J, Hardeman W, et admitted to hospital. Age Ageing. 2004;33:110–5. al. The behavior change technique taxonomy (v1) of 93 hierarchically 17. Caplan GA, Brown A, Croker WD, Doolan J. Risk of admission within 4 weeks clustered techniques: building an international consensus for the reporting of discharge of elderly patients from the emergency department--the DEED of behavior change interventions. Ann Behav Med. 2013;46:81–95. study. Discharge of elderly from emergency department. Age Ageing. 1998; 41. Freiberger E, de Vreede P, Schoene D, Rydwik E, Mueller V, Frandin K, et al. 27:697–702. Performance-based physical function in older community-dwelling persons: 18. Abizanda P, Leon M, Dominguez-Martin L, Lozano-Berrio V, Romero L, a systematic review of instruments. Age Ageing. 2012;41:712–21. Luengo C, et al. Effects of a short-term occupational therapy intervention in 42. Podsiadlo D, Richardson S. The timed "Up & Go": a test of basic functional an acute geriatric unit. A randomized clinical trial. Maturitas. 2011;69:273–8. mobility for frail elderly persons. J Am Geriatr Soc. 1991;39:142–8. 19. Courtney M, Edwards H, Chang A, Parker A, Finlayson K, Hamilton K. Fewer 43. Jones CJ, Rikli RE, Beam WC. A 30-s chair-stand test as a measure of lower body emergency readmissions and better quality of life for older adults at risk of strength in community-residing older adults. Res Q Exerc Sport. 1999;70:113–9. hospital readmission: a randomized controlled trial to determine the 44. Fisher AG, Bray K. Assessment of motor and process skills. Development, effectiveness of a 24-week exercise and telephone follow-up program. J Am standardization, and administration manual. 7th ed. Colorado: Fort Collins Geriatr Soc. 2009;57:395–402. Three Star Press; 2007. 20. Gitlin LN, Hauck WW, Dennis MP, Winter L, Hodgson N, Schinfeld S. Long- 45. Merritt BK. Validity of using the assessment of motor and process skills to term effect on mortality of a home intervention that reduces functional determine the need for assistance. Am J Occup Ther. 2011;65:643–50. Nielsen et al. BMC Health Services Research (2018) 18:588 Page 11 of 11

46. Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauly MV, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281:613–20. 47. Mahoney FI, Barthel DW. Functional evaluation: the Barthel index. Md State Med J. 1965;14:61–5. 48. Collin C, Wade DT, Davies S, Horne V. The Barthel ADL index: a reliability study. Int Disabil Stud. 1988;10:61–3. 49. Haywood KL, Garratt AM, Fitzpatrick R. Quality of life in older people: a structured review of generic self-assessed health instruments. Qual Life Res. 2005;14:1651–68. 50. Ustun TB, Chatterji S, Kostanjsek N, Rehm J, Kennedy C, Epping-Jordan J, et al. Developing the World Health Organization disability assessment schedule 2.0. Bull World Health Organ. 2010;88:815–23. 51. Fusch PI, Ness LR. Are we there yet? Data saturation in qualitative research. Qual Rep. 2015;20:1408–16. 52. Rosted E, Poulsen I, Hendriksen C, Petersen J, Wagner L. Testing a two step nursing intervention focused on decreasing rehospitalizations and nursing home admission post discharge from acute care. Geriatr Nurs. 2013;34:477–85. 53. Biese K, Lamantia M, Shofer F, McCall B, Roberts E, Stearns SC, et al. A randomized trial exploring the effect of a telephone call follow-up on care plan compliance among older adults discharged home from the emergency department. Acad Emerg Med. 2014;21:188–95. 54. Rytter L, Jakobsen HN, Ronholt F, Hammer AV, Andreasen AH, Nissen A, et al. Comprehensive discharge follow-up in patients' homes by GPs and district nurses of elderly patients. A randomized controlled trial. Scand J Prim Health Care. 2010;28:146–53. 55. Torisson G, Minthon L, Stavenow L, Londos E. Multidisciplinary intervention reducing readmissions in medical inpatients: a prospective, non-randomized study. Clin Interv Aging. 2013;8:1295–304.

Paper II Journal name: Clinical Interventions in Aging Article Designation: Original Research Year: 2018 Volume: 13 Clinical Interventions in Aging Dovepress Running head verso: Nielsen et al Running head recto: Effectiveness of the Elderly Activity Performance Intervention open access to scientific and medical research DOI: 162623

Open Access Full Text Article Original Research Effectiveness of the “Elderly Activity Performance Intervention” on elderly patients’ discharge from a short-stay unit at the emergency department: a quasi-experimental trial

Louise Moeldrup Nielsen1,2 Purpose: To examine the effectiveness of the Elderly Activity Performance Intervention on Thomas Maribo3 reducing the risk of readmission in elderly patients discharged from a short-stay unit at the Hans Kirkegaard4 emergency department. Kirsten Schultz Petersen5 Patients and methods: The study was conducted as a nonrandomized, quasi-experimental Marianne Lisby4 trial. Three hundred and seventy-five elderly patients were included and allocated to the Elderly Lisa Gregersen Activity Performance Intervention (n=144) or usual practice (n=231). The intervention consisted of 1) assessment of the patients’ performance of daily activities, 2) referral to further rehabilita- Oestergaard2,6 For personal use only. tion, and 3) follow-up visit the day after discharge. Primary outcome was readmission (yes/no) 1 Department of Occupational Therapy, within 26 weeks. The study was registered in ClinicalTrial.gov (NCT02078466). VIA University College, 2Department of Physiotherapy and Occupational Results: No between-group differences were found in readmission. Overall, 44% of the Therapy, Aarhus University Hospital, patients in the intervention group and 42% in the usual practice group were readmitted within 3 Department of Public Health, 26 weeks (risk difference=0.02, 95% CI: [−0.08; 0.12] and risk ratio=1.05, 95% CI: [0.83; 1.33]). Aarhus University, DEFACTUM, 4Department of Clinical Medicine, No between-group differences were found in any of the secondary outcomes. Research Centre for Emergency Conclusion: The Elderly Activity Performance Intervention showed no effectiveness in Medicine, Aarhus University Hospital, reducing the risk of readmission in elderly patients discharged from a short-stay unit at the Aarhus, 5Department of Health Science and Technology, Aalborg emergency department. The study revealed that 60% of the elderly patients had a need for University, Aalborg, 6Department of further rehabilitation after discharge. Clinical Medicine, Aarhus University and Aarhus University Hospital, Keywords: occupational therapy, rehabilitation, performance of daily activities, activities of Aarhus, Denmark daily living, acute care Clinical Interventions in Aging downloaded from https://www.dovepress.com/ by 87.54.33.144 on 25-May-2018

Introduction The number of elderly people admitted to an emergency department (ED) is increasing and today, elderly patients (65+) account for up to 25% of all ED admissions.1–4 Elderly patients discharged from the ED are at high risk of adverse outcomes such as readmission and death.5–8 Some of the risk factors leading to readmission are limitations in performing daily activities, comorbidity, and changes in medical condition.6–10 A large proportion of the elderly patients admitted to the ED are discharged directly to their home.4 After discharge, they often need treatment, care, and rehabilitation from Correspondence: Louise Moeldrup both hospital and primary care.4,8 A safe and coherent discharge of elderly patients is, Nielsen therefore, highly dependent on effective collaboration between health care providers Department of Occupational Therapy, VIA University College, Hedeager 2, across hospital and primary care sectors.11,12 8200 Aarhus, Denmark Studies emphasize that current ED discharge processes should be optimized to Tel +45 5124 5081 Email [email protected] meet the complex needs of elderly patients.8,13,14 So far, a number of interventions have

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Nielsen et al Dovepress

been designed to improve the outcomes of elderly patients Participant enrollment and setting discharged from the ED, including comprehensive geriatric The first part of the intervention took place in the period assessment, discharge planning, follow-up initiatives, and March–December 2014 at a short-stay unit in the ED at a 1,150- care transition interventions. However, the evaluations of the bed university hospital in Denmark, where ~42,000 patients effectiveness of these interventions vary.15–19 A meta-analysis are visiting the ED annually. In Denmark, a short-stay unit from 2011 concluded that there was no clear evidence support- provides treatment and care for up till 48 hours, followed ing comprehensive geriatric assessment in terms of reducing by patient discharge or transfer to an in-patient unit. The risk of readmission.20 In accordance with the review from second part of the intervention took place at the patients’ 2011, a meta-analysis from 2015 concluded that there was home after discharge. In Denmark, the health care system is no effect of care transition interventions on reducing read- tax-financed and free of charge; home-based rehabilitation mission and mortality rates.21 However, a systematic review is offered after hospitalization. from 2016 implied that pre-discharge interventions consisting The following criteria were used to recruit participants. of a follow-up visit after discharge may reduce the risk of readmission.22 Follow-up visits have been recommended as Inclusion criteria a way to ensure sustainable care for elderly patients after dis- • Patients age 65+ charge from the hospital.14,15,18,23 Only a few studies aiming to • Patients admitted with a medical diagnosis (as distinct reduce the risk of readmission in elderly patients have focused from surgical or psychiatric diagnosis) to the short-stay on enhancing performance of daily activities, although it is a unit well-known high-risk factor for readmission.6,10,15,24 • Patients who were residents in a larger municipality Occupational therapy as part of the hospital discharge (Aarhus) in Denmark generally aims at enhancing the patients’ performance of daily activities and ensuring that discharge and transition Exclusion criteria of elderly patients’ rehabilitation needs are coordinated.25,26 • Patients transferred to other hospital departments For personal use only. In Denmark, occupational therapy as part of hospital dis- • Patients admitted from a nursing home charge planning is not a part of the standard discharge • Patients who were unable to communicate in Danish procedure of elderly patients at the ED.27 A focus on elderly • Patients declared terminally ill patients’ performance of daily activities and on ensuring a coherent discharge may be essential in reducing elderly Patient allocation patients’ risk of readmission after discharge, as these factors Each week day at 8:00 am, a research occupational therapist are associated with the risk of readmission.7,10,12 reviewed a list of all patients admitted in the last 24 hours The current study proposes a novel discharge planning and screened them for eligibility. Due to limited resources intervention focusing on two risk factors in the prevention of and time, it was possible to include and allocate up to two readmissions: 1) to enhance performance of daily activities patients to the intervention group per day. If more patients

Clinical Interventions in Aging downloaded from https://www.dovepress.com/ by 87.54.33.144 on 25-May-2018 and 2) to ensure a coherent discharge to home. The “Elderly were eligible, allocation was based on the date of birth Activity Performance Intervention” (EAP-intervention) was (day of the month). The two patients born closest to the developed and designed as a theory- and evidence-based first day of a month (eg, March 1) would be allocated to the intervention using the Intervention Mapping approach.28,29 intervention group. Patients not included in the intervention The objective of this study was to examine the effective- group were treated according to usual practice and formed ness of the EAP-intervention compared to usual practice in the control group. Likewise, patients admitted after 8:00 am terms of reducing the risk of readmission in elderly patients and meeting the inclusion criteria, but were discharged out discharged from the ED. We hypothesized that the interven- of hours (afternoons and evenings) were allocated to the tion would be superior to usual practice in reducing the risk usual practice group. of readmission measured 26 weeks after discharge. Interventions Patients and methods Usual practice Design Patients in both groups received relevant medical treatment A nonrandomized, quasi-experimental, parallel study was and care. Referral to occupational therapy and physiotherapy conducted. Follow-up was performed at 30 days and at took place only if the medical or nursing staff considered 26 weeks after discharge from the short-stay unit at the ED. it necessary. If the occupational therapist was summoned

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Dovepress Effectiveness of the Elderly Activity Performance Intervention

to asses a patient, the occupational therapist performed a were determined using the following cut-off values: Time short interview and a non-standardized observation of the Up and Go .12 seconds,35 Chair Stand Test ,8 times in patient’s performance of basic daily activities and the results 30 seconds,36 and Assessment of Motor and Process Skills were communicated to the municipality homecare staff. If motor ability ,1.50 logits and process ability ,1.00 logits.33 necessary, nurses from the ED organized referral to nursing Component 1 was provided for all patients. Based on the home care after discharge. results in component 1, patients with limitations in performing daily activities received components 2 and 3. The EAP-intervention The EAP-intervention was offered in addition to usual Component 2 practice. An extended description of how the intervention A rehabilitation plan was prescribed for patients with identi- was developed and designed in accordance with theory fied limitations in performing daily activities. The rehabilita- and evidence is reported elsewhere.29 The intervention was tion plan included a description of the patient’s previous and initiated immediately after the patient was allocated to the current performance of daily activities and specified the need intervention group. The intervention consisted of three com- for further rehabilitation. Primary care was informed about ponents (Figure 1). the discharge, and visitation of the patient to further rehabilitation interventions was carried out on the same day in order Component 1 to start the rehabilitation immediately after discharge. Assessment of the patients’ performance of daily activities using three performance-based measures: Timed Up and Component 3 Go,30,31 30s-Chair Stand Test,32 and Assessment of Motor and For patients with a prescribed rehabilitation plan, a home Process Skills.33,34 Limitations in performing daily activities visit by an occupational therapist was performed the day

For personal use only. Component 1: assessment (emergency department) Assessment of performance of daily activities with performance-based measures; • Timed Up and Go (TUG) • 30s-Chair Stand Test (30s-CST) • Assessment of Motor and Process Skills (AMPS) Cut-off points, identified in the literature were used to determine the need for further rehabilitation (components 2 and 3). Day 0

Component 2: rehabilitation plan The OT drafts a rehabilitation plan for patients with identified rehabilitation need and refers the patient to further rehabilitation in primary care. Clinical Interventions in Aging downloaded from https://www.dovepress.com/ by 87.54.33.144 on 25-May-2018

Component 3: follow-up visit (patient home) The day after discharge from the emergency department, the OT visits the patient at home with the aim of enhancing the patient’s performance of daily activities and to ensure a coherent discharge. General approach: adaptive/compensatory, acquisitional, and restorative • Screening of the home for safety risk and factors that potently limit Day 1 the performance of daily activities, by using a standardized checklist • Use of alternative and compensatory strategies to improve daily activities • Advice on appropriate assistive device and adaption in the environment to enhance independence, efficiency, and safety in performing daily activities • Advice on how to perform daily activities in new routines • Train skills (motor and process)

Figure 1 Overview of the Elderly Activity Performance Intervention. Abbreviation: OT, occupational therapist.

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after discharge. The home visit aimed to enhance the patient’s and SD or numbers and percentages. The two groups were performance of daily activities and to start rehabilitation. The compared and tested for significant differences at baseline occupational therapist screened the home for safety risks and using chi-square test, the Student’s t-test for normally dis- factors that potently could limit the performance of daily tributed continuous variables, and the Wilcoxon rank sum activities. If limitations and/or safety risks were identified, test for nonparametric variables. Risk of readmission within the occupational therapist made relevant modifications of 26 weeks was estimated by cumulative incidence propor- the home environment. To ensure standardized procedures tion using a pseudo-value method accounting for death as a at the follow-up visit, a checklist was developed. competing risk.42,43 The two groups were compared by risk None of the three components in the EAP-intervention difference (RD) and risk ratio (RR) with 95% CI. Due to the were applied to patients in the usual practice group. nonrandomized study design, similar analysis was performed by adjusting for factors that a priori were considered to be Outcomes confounders: age, gender, and comorbidity. Thirty-day all- The primary outcome was all-cause readmission within cause readmission and all-cause mortality within 26 weeks 26 weeks. Secondary outcomes were all-cause readmission were estimated by RD and RR with 95% CI and secondly within 30 days and all-cause mortality, number of contacts to adjusted for potential confounding. Numbers of contacts to general practitioners (GPs) and EDs (without admission) within GPs and ED were described with median and range and dif- 26 weeks, and time to first readmission. All data on outcome ferences were tested with nonparametric Wilcoxon rank sum variables were obtained from the National Patient Register. test. Time to first readmission with unadjusted cumulative Data related to patient characteristics were extracted for incidence proportions was illustrated in a graph. An explor- both groups from the National Patient Register and included ative analysis was performed to compare the baseline dif- gender, age, civil status, admission diagnosis, comorbidity, ferences for those patients in the control group admitted and admission time. Comorbidity was measured with the during the daytime and those admitted during afternoon Charlson’s Comorbidity Index calculated from International and evenings, in order to include possible differences in the For personal use only. Statistical Classification of Diseases and Related Health adjusted analyses. An exploratory analysis within the inter- Problems 10th Revision diagnosis retrieved from the National vention group was performed to examine if the number of Patient Register, at the day of inclusion.37–39 intervention components received was associated with the primary outcome, risk of readmission within 26 weeks. Sample size estimation Based on the literature, the intervention was expected to Ethical approval and registrations reduce the risk of readmission within 26 weeks with 16 per- The ethical principles of the World Medical Association centage points, from 37% to 21%.17 A total of 152 patients Declaration of Helsinki were followed.44 The Regional Ethics in each group were needed to achieve 80% power with a Committee responded that no approval was required as the two-sided type I error of 5%, assuming that 10% of the par- study was classified as a quality assurance project (J. nr.1-

Clinical Interventions in Aging downloaded from https://www.dovepress.com/ by 87.54.33.144 on 25-May-2018 ticipants were lost to follow-up, for example, due to death. 10-72-108-14). The study was approved by the Danish Data Protection Agency (J.nr. 2012-41-0763) and by the Danish Statistical methods Health Authority (3-3013-608/1/). The study was registered A detailed statistical analysis plan was developed prospectively in ClinicalTrial.gov (NCT02078466). Patients included and in accordance with the Standard Protocol Items: Recommen- allocated to the intervention group provided written informed dations for Interventional Trials (SPIRIT) statement, and data consent. Patients allocated to the usual practice group were were reported according to the extended Consolidated Stan- not informed about their participation, as only data from dards of Reporting Trials (CONSORT) statement.40,41 Hypoth- the National Patient Registry were used. The Danish Health esis tests were conducted at the 5% level of significance and Authority gave permission to obtain health-related data on were two-sided. All analyses were performed using the Stata patients in the usual practice group. 14.2 statistics program. Biostatistician was consulted in developing the analysis plan and when performing the analyses. Results First, a descriptive analysis was performed summarizing During the inclusion period, 945 patients were screened for baseline characteristics for both the intervention group and eligibility. A total of 410 patients met the inclusion crite- the usual practice group. Data were presented as mean ria; 35 declined to participate. A total of 375 participants

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Dovepress Effectiveness of the Elderly Activity Performance Intervention

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Figure 2 Flowchart of the study population. For personal use only. were enrolled in the study; 144 were allocated to the EAP- comparing those admitted in daytime with those admitted intervention and 231 to the usual practice group. The enroll- during afternoon and evenings. Patients in the usual practice ment of study participants is shown in Figure 2. No partici- group who were included in daytime had longer admission pants were excluded from the analysis. time; 1.06 (0.88; 1.92) vs 0.73 (0.42; 0.96) p,0.001 than Participant characteristics at baseline are shown in Table 1. those admitted during afternoons and evenings. Also, 47% Overall, the two groups appeared comparable at baseline of the patients in the usual practice group who were admit- concerning gender, diagnosis at discharge, comorbidity, and ted in the afternoons and evenings and 34% of the patients marital status. Patients in the intervention group were older admitted in daytime were married (p=0.044). Adjusting for on average than patients in the usual practice group (81 vs those factors in combination with the a priori confounders 78 years, p=0.003), and patients in the intervention group age, gender, and comorbidity did not show any significant

Clinical Interventions in Aging downloaded from https://www.dovepress.com/ by 87.54.33.144 on 25-May-2018 were admitted longer than patients in the usual practice group difference in either readmission within 26 weeks or readmis- (0.94 [0.74; 1.33] vs 0.82 [0.57; 1.09] days, p=0.002). sion within 30 days (Table 2).

Readmission Mortality No between-group differences were found regarding the pri- Overall, the mortality 26 weeks after discharge was 10% in mary outcome readmission. A total of 44% of the patients in both groups. Adjustment for potential confounding did not the intervention group and 42% of patients in the usual practice show any difference (Table 2). group were readmitted within 26 weeks (RD=0.02, 95% CI: [−0.08; 0.12] and RR=1.05, 95% CI: [0.83; 0.33]), as shown in Table 2 and Figure 3. There was no difference in 30 days Contacts to GP and ED readmission; 18% of the patients in the intervention group were The median number of contacts to the ED within a period of readmitted and 23% in the usual practice group (RD=−0.05, 26 weeks from inclusion in both groups was zero (Table 3). 95% CI: [−0.13; 0.03] and RR=0.78, 95% CI: [0.51; 1.19]). A total of 21% of the patients in the intervention group and The within-group analysis of the usual practice group 17% from the usual practice group had at least one contact revealed differences in marital status and admission time on to the ED during the 26 weeks.

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Table 1 Baseline characteristics of the study population (N=375) Characteristics Intervention Usual practice Test for (n=144) (n=231) difference Mean age, years (SD) 81 (7.9) 78 (8.6) p=0.003 Female, n (%) 79 (55) 122 (53) p=0.699 Marital status, n (%) p=0.171 Widowed 48 (33) 68 (29) Divorced 33 (23) 41 (18) Married 56 (39) 99 (43) Single 7 (5) 23 (10) Diagnosis at discharge, n (%) p=0.968 Infectious and parasitic diseases 2 (1.4) 1 (0.4) Neoplasms 13 (9.0) 21 (9.1) Diseases of the blood 1 (0.7) 1 (0.4) Endocrine and metabolic diseases 7 (4.9) 12 (5.2) Diseases in the nervous system 4 (2.8) 7 (3.0) Diseases of the eye and adnexa 7 (4.9) 5 (2.2) Diseases of the ear and mastoid process 3 (2.1) 8 (3.5) Diseases in the circulatory system 17 (11.8) 30 (13.0) Diseases in the respiratory system 8 (5.6) 12 (5.2) Diseases of the digestive system 4 (2.8) 9 (3.9) Diseases of the skin 2 (1.4) 2 (0.8) Musculoskeletal diseases 13 (9.0) 25 (10.8) Diseases of the genitourinary system 3 (2.1) 8 (3.5) Symptoms and abnormal clinical findings 13 (9.0) 22 (9.5) Injury 10 (6.9) 20 (8.7) Factors influencing health status 37 (25.7) 48 (20.8) Comorbidity, n (%)a p=0.183 For personal use only. Low: score 0–1 75 (52) 131 (57) Moderate: score 2–3 45 (31) 62 (27) High: score .4 24 (17) 38 (16) Days of admission, median (IQR) 0.94 (0.74; 1.33) 0.82 (0.57; 1.09) p=0.002 Note: aCharlson’s Comorbidity Index. Abbreviation: IQR, interquartile range.

A total of 97% of the patients in the intervention group in the intervention group were assessed with at least one of and 99% from the usual practice group had at least one the performance-based assessments in component 1. Based contact to the GP during the 26 weeks. The median number on the results from the assessment, a total of 87 (60%) of the of contacts to the GP for both groups was 9. patients in the intervention group were referred to primary

Clinical Interventions in Aging downloaded from https://www.dovepress.com/ by 87.54.33.144 on 25-May-2018 care rehabilitation (component 2). Of these, 69 (79%) patients Exploratory analysis within the received a follow-up visit by the occupational therapist the intervention group day after discharge (component 3). Table 4 shows the number of patients receiving each An exploratory analysis within the intervention group component of the intervention and the results from the showed that 51% of the patients who had a need for all of performance-based assessment in component 1. All patients the components in the EAP-intervention were readmitted

Table 2 Comparison of risk of readmission and risk of mortality for the study population (N=375) Outcomes Intervention Usual practice Risk difference Risk ratio (n=144) (n=231) Crude Adjusteda Crude Adjusteda (95% CI) (95% CI) (95% CI) (95% CI) Readmission 26 weeks, n (%) 64 (44) 99 (42) 0.02 (−0.08; 0.12) 0.02 (−0.09; 0.12) 1.05 (0.83; 1.33) 1.07 (0.84; 1.36) Readmission 30 days, n (%) 25 (18) 55 (23) −0.05 (−0.13; 0.03) −0.04 (−0.12; 0.04) 0.78 (0.51; 1.19) 0.83 (0.51; 1.35) Mortality 26 weeks, n (%) 14 (10) 23 (10) −0.00 (−0.06; 0.06) −0.01 (−0.09; 0.8) 0.98 (0.52; 1.83) 1.06 (0.68; 1.66) Note: aAdjusted for age, gender, admission time, marital status, and comorbidity measured with CCI. Abbreviation: CCI, Charlson’s Comorbidity Index.

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Dovepress Effectiveness of the Elderly Activity Performance Intervention

Table 4 Number of patients receiving each component of the EAP-intervention and results from the performance-based assessment in component 1 (n=144) Intervention components n (%) Score

LQFLGHQFH &XPXODWLYH Component 1a Assessment of activity limitations 144 (100) Assessment with TUGb, median (IQR) 120 (83) 11.8 (8.8–17.7) :HHNVVLQFHGLVFKDUJH Assessment with 30s-CSTc, median (IQR) 126 (88) 7 (0–10) 8VXDOSUDFWLFH ,QWHUYHQWLRQ Assessment with AMPSd motor, mean (SD) 96 (67) 1.02 (0.79) Assessment with AMPS process, mean (SD) 0.93 (0.80) Figure 3 Plots of cumulative incidence proportion for readmission within 26 weeks Component 2 for the study population (N=375). Rehabilitation plan 87 (60) Component 3 within 26 weeks compared to 33% of the patients who Follow-up visit 69 (48) Notes: aAll patients in the intervention group were assessed with at least one of only had need for component 1 (RD=0.18, 95% CI: [0.02; the performance-based measures in component 1. bScore for TUG is in seconds. 0.35] and RR=1.55, 95% CI: [1.02; 2.36]), as shown in A score .12 seconds reflects limitations.35 cScore for 30s-CST reflects how many times a person can rise from a chair in 30 seconds. A score ,8 reflects limitations.36 Table 5. dScore for AMPS is in logits. A score ,1.50 logits in motor ability and .1.00 logits in process ability reflect limitations.33 Abbreviations: AMPS, Assessment of Motor and Process Skills; CST, Chair Stand Discussion Test; EAP, Elderly Activity Performance; IQR, interquartile range; TUG, Timed Up The aim of this nonrandomized, quasi-experimental, parallel and Go. study was to examine the effectiveness of the EAP-intervention compared to usual practice on reducing the risk of readmis- enhance the elderly patients’ performance of daily activities sion in elderly patients discharged from a short-stay unit at and ensure a coherent discharge to home, assuming that this the ED. We did not find the EAP-intervention to be superior would reduce the risk of readmission. This assumption was For personal use only. compared to usual practice in reducing the risk of readmission based on evidence in the literature and the use of a logic model in our study population. In addition, none of the secondary as recommended in the Intervention Mapping approach.28,29 outcomes differed significantly between the two groups. The use of a logic model in the developing phase allowed us When exploring the effectiveness in relation to different to focus directly on factors and their underlying determinants subgroups such as gender, comorbidity, and age, no differ- associated with risk of readmission. Although limitations in ences were found. performing daily activities are a well-known risk factor for The intention with the EAP-intervention was to improve readmission in elderly patients, the EAP-intervention may not usual practice by enhancing the elderly patients’ performance have been sufficiently intensive to address the complexity in of daily activities and ensure a coherent discharge, without the health needs of elderly patients as only two factors were changing the overall organization of the Danish health specifically addressed: performance of daily activities and care system. 7,10,12 Clinical Interventions in Aging downloaded from https://www.dovepress.com/ by 87.54.33.144 on 25-May-2018 a coherent discharge. Other risk factors for readmis- We hypothesized that the EAP-intervention was more sion, such as nutritional status and polypharmacy, were not efficient compared to usual practice, but our results did not specifically addressed in this intervention, although they are corroborate this. The EAP-intervention was developed to known to be important elements in geriatric interventions.18,23 Further studies should investigate the effectiveness of a Table 3 Contacts to GP and the ED within 26 weeks for the multidisciplinary approach in a multicomponent interven- study population (N=375) tion addressing the ability to perform daily activities and Contacts Intervention Usual practice Test for other selected factors such as psychosocial, socioeconomic, (n=144) (n=231) difference nutritional, and medication. Contacts to ED Although the EAP-intervention was designed to address n (%) 30 (21) 39 (17) p=0.337 Median (IQR) 0 (0–0) 0 (0–0) the patients’ performance of daily activities, the design of Contacts to GP the study did not allow us to test its effectiveness on the n (%) 139 (97) 228 (99) p=0.157 patients’ performance of daily activities. This was due to Median (IQR) 9 (5–14) 9 (5–13) the fact that the assessments of the patients’ performance Abbreviations: ED, emergency department; GP, general practitioner; IQR, inter quartile range. of daily activities were one of the three components of the

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Table 5 Risk of readmission in the intervention group (n=144) Readmission Need for components 2 Only component 1 Risk difference Risk ratio and 3a (n=87) necessaryb (n=57) (95% CI) (95% CI) Readmission 26 weeks, n (%) 45 (51) 19 (33) 0.18 (0.02; 0.35) 1.55 (1.02; 2.36) Notes: aNeed for components 2 and 3: based on the assessment in component 1, the patient was identified with limitations in performing daily activities and a need for further rehabilitation. bComponent 1: assessment of performance of daily activities.

EAP-intervention. It would have been preferable to collect therapy discharge planning intervention would be beneficial other measures on performance of daily activities for patients in reducing the risk of readmission in elderly patients. in both groups. However, this was not possible as solely The exploratory analysis within the intervention group register-based data were collected in the usual practice revealed that patients (60%) who were identified with group. Measures on the performance of daily activities decreased ability to perform daily activities in component 1 may have contributed with a deeper insight to whether the were at higher risk of readmission within 26 weeks than EAP-intervention resulted in enhancing the elderly patients’ patients with no limitations in performing daily activities. This performance of daily activities. A more comprehensive inter- indicates that a large proportion of elderly patients discharged vention, including task-specific training over a longer period, from short-stay units at EDs have limitations in performing may potentially increase elderly patients’ performance of daily activities and thereby need further rehabilitation. daily activities. Benefits from such interventions in elderly populations have been described broadly.45–48 A systematic Strength and limitations review of home- and community-based occupational therapy Due to the quasi-experimental design, we were able to from 2017 concluded that there is strong evidence that include nearly all patients meeting the inclusion criteria, occupational therapy improves the ability to perform daily thus providing a representative result. The intervention was activities in elderly.45 performed during routine clinical practice and not in selected For personal use only. Participants in our study were comparable with partici- cases, which enhances the clinical relevance. Furthermore, pants in similar studies with regard to age and comorbidity, an important strength of the study is the use of register-based but may have differed in other factors such as socioeco- data, which ensured a complete follow-up (100%) on all nomic status or home care received before admission.15,49 outcomes measured. Age at 65 or above was an inclusion criterion in our study, The study did have some limitations. First, the nonran- which is in accordance with other studies aimed at reducing domized allocation may have led to unequal distribution of the risk of readmission in elderly patients.19,49 We did not unmeasured factors, for example, socioeconomic factors or select the participants due to their limitations in performing physical functioning between the two groups. Although the daily activities or other factors associated with the risk of patients in the two groups were similar in terms of gender, readmission. If we had used a risk stratification instrument marital status, and comorbidity, patients in the intervention

Clinical Interventions in Aging downloaded from https://www.dovepress.com/ by 87.54.33.144 on 25-May-2018 to screen and identify patients at high risk of readmission, group were older and admitted longer than patients in the it may have resulted in a different study population. Our usual practice group. In the statistical analyses, we used a results showed that 60% of patients in the intervention group multiple regression model to control for those differences had limitations in performing daily activities as identified in baseline characteristics. However, there may be several with the performance-based assessment of performance of unidentified or unmeasured confounding factors that possibly daily activities (component 1) and, thereby, the need for a could have influenced the outcome. rehabilitation plan and follow-up visits by an occupational Given the available resources and experiences from a pre- therapist (components 2 and 3). If we had used a risk stratifi- vious pilot study, a randomized trial was not a viable option.29 cation instrument to select patients at high risk, we may have In our previous pilot study, the randomization procedures included a more homogenous population, which potentially were not feasible for the patients, which resulted in 67% of could have benefitted from the EAP-intervention. Two sys- the patients refusing to participate. The quasi-experimental tematic reviews highlight that studies using risk stratification study design may be inferior to the randomized controlled instruments to identify high-risk patients most frequently trials on the study design hierarchy. However, the use of it show beneficial results.14,50 Further research is needed in may be beneficial in situations where randomization is not order to examine if risk stratification before an occupational an option.51

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Dovepress Effectiveness of the Elderly Activity Performance Intervention

Allocation of patients to the usual practice group may primary care/the municipality who actively participated in have introduced selection bias, as some of the patients this project. were included in daytime and others in afternoons and The work was supported by the Tryg Foundation (grant evenings. The within-group analysis of the usual practice number 107632), the Foundation of Public Health in the group revealed differences in the group in relation to marital Middle (grant number 1-30-72-141-12), and Aase and Ejnar status and admission time. This was handled by adjusting for Danielsen’s Foundation (grant number 10-001233). The the influence of these two factors in the analyses, and the foundations played no role in the design, execution, analysis, subanalysis did not alter the overall findings of the study. and interpretation of data, or writing of the study. Referral to further rehabilitation in the municipality was planned to be carried out immediately after discharge from Disclosure the hospital. However, it was not possible to get data on the The authors report no conflicts of interest in this work. actual services delivered from the municipality, and we do not know whether rehabilitation in primary care was carried References out as planned. This may have affected the impact of the 1. McCabe JJ, Kennelly SP. Acute care of older patients in the emergency department: strategies to improve patient outcomes. Open Access Emerg intervention on the risk of readmission, and the lack of data Med. 2015;7:45–54. is considered a limitation of the study. 2. Hastings SN, Barrett A, Weinberger M, et al. Older patients’ understanding of emergency department discharge information and its relationship Due to the nature of the study, we were not able to blind with adverse outcomes. J Patient Saf. 2011;7:19–25. patients or staff at the short-stay unit as to who received 3. Samaras N, Chevalley T, Samaras D, Gold G. Older patients in the emer- the intervention. In order to reduce the possibility of con- gency department: a review. Ann Emerg Med. 2010;56:261–269. 4. Danish Health and Medicine Authority. Enhanced Efforts for the Elderly tamination, the occupational therapists delivering the EAP- Medical Patient–Approach for a National Action Plan. Copenhagen: intervention were not allowed to treat patients in the usual Danish Health and Medicine Authority; 2011. 5. Xu KT, Nelson BK, Berk S. The changing profile of patients who used practice group. None of the patients in the usual practice emergency department services in the United States: 1996 to 2005. group received follow-up visits after discharge, though some Ann Emerg Med. 2009;54:805–810.e1–7. For personal use only. of them may have, by self-referral, received some kind of 6. Deschodt M, Devriendt E, Sabbe M, et al. Characteristics of older adults admitted to the emergency department (ED) and their risk factors rehabilitation and/or home care after discharge. for ED readmission based on comprehensive geriatric assessment: a prospective cohort study. BMC Geriatr. 2015;15:54. 7. Greysen SR, Stijacic Cenzer I, Auerbach AD, Covinsky KE. Functional Conclusion impairment and hospital readmission in Medicare seniors. JAMA Intern Med. 2015;175:559–565. The EAP-intervention showed no effectiveness in reducing 8. McCusker J, Roberge D, Vadeboncoeur A, Verdon J. Safety of discharge the risk of readmission in elderly patients discharged from a of seniors from the emergency department to the community. Healthc Q. short-stay unit at the ED. The results highlight the importance 2009;12t:24–32. 9. Campbell SE, Seymour DG, Primrose WR, ACMEPLUS Project. of assessing elderly patients’ ability to perform daily activi- A systematic literature review of factors affecting outcome in older ties before discharge in order to determine the need for further medical patients admitted to hospital. Age Ageing. 2004;33:110–115. 10. Matzen LE, Jepsen DB, Ryg J, Masud T. Functional level at admission rehabilitation. Although the intervention was not effective Clinical Interventions in Aging downloaded from https://www.dovepress.com/ by 87.54.33.144 on 25-May-2018 is a predictor of survival in older patients admitted to an acute geriatric in reducing the risk of readmission, it revealed that 60% unit. BMC Geriatr. 2012;12:32. of patients in the intervention group had decreased ability 11. Krevers B, Narvanen AL, Oberg B. Patient evaluation of the care and rehabilitation process in geriatric hospital care. Disabil Rehabil. 2002; to perform daily activities and there was a need for further 24:482–491. rehabilitation after discharge. Further studies are needed to 12. Slatyer S, Toye C, Popescu A, et al. Early re-presentation to hospital after discharge from an acute medical unit: perspectives of older patients, examine if a more intensive occupational therapy interven- their family caregivers and health professionals. J Clin Nurs. 2013; tion with task-specific training over a longer period will 22:445–455. increase elderly patients’ ability to perform daily activities 13. Bachmann S, Finger C, Huss A, Egger M, Stuck AE, Clough-Gorr KM. Inpatient rehabilitation specifically designed for geriatric patients: sys- and, thereby, reduce their risk of readmission after discharge tematic review and meta-analysis of randomised controlled trials. BMJ. from a short-stay unit at the ED. 2010;340:c1718. 14. Karam G, Radden Z, Berall LE, Cheng C, Gruneir A. Efficacy of emergency department-based interventions designed to reduce repeat visits and other adverse outcomes for older patients after discharge: Acknowledgments a systematic review. Geriatr Gerontol Int. 2015;15:1107–1117. We are grateful to the participants and their relatives, the 15. Caplan GA, Williams AJ, Daly B, Abraham K. A randomized, controlled trial of comprehensive geriatric assessment and multidisciplinary inter- occupational therapists, physiotherapist, doctors, and nurses vention after discharge of elderly from the emergency department–the at the participating short-stay unit, and to therapists from DEED II study. J Am Geriatr Soc. 2004;52:1417–1423.

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Nielsen LM, Maribo T, Kirkegaard H, et al. Clinical 1Department of Physiotherapy and Occupational Therapy, Interventions in Aging. 2018;13:737–747. Aarhus University Hospital, Aarhus, Denmark; 2Department of Occupational Therapy, VIA University College, Aarhus, On page 737, the author affiliations were listed incorrectly. Denmark; 3Research Centre for Emergency Medicine, They should have been listed as follows: Aarhus University Hospital, Aarhus, Denmark; 4Department of Public Health, Aarhus University, Aarhus, Denmark; Louise Moeldrup Nielsen1–3 5DEFACTUM, Central Denmark Region, Aarhus, Denmark; Thomas Maribo4,5 6Department of Health Science and Technology, Aalborg Hans Kirkegaard3 University, Aalborg, Denmark; 7Centre of Research in Kirsten Schultz Petersen6 Rehabilitation (CORIR), Department of Clinical Medicine, Marianne Lisby3 Aarhus University and Aarhus University Hospital, Aarhus, Lisa Gregersen Oestergaard1,4,7 Denmark For personal use only. Clinical Interventions in Aging downloaded from https://www.dovepress.com/ by 87.54.33.144 on 17-Oct-2018

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Paper III Title page: Returning to everyday life after discharge from a short-stay unit at the Emergency Department– a qualitative study of elderly patients’ experiences

Louise Moeldrup Nielsena, b, c* ORCID: 0000-0002-3362-6275

Lisa Gregersen Oestergaard a, d, e

Thomas Maribo d, f

Hans Kirkegaardc

Kirsten Schultz Peterseng

a Department of Physiotherapy and Occupational Therapy, Aarhus University Hospital, Aarhus, Denmark. b Department of Occupational Therapy, VIA University College, Aarhus, Denmark. c Research Centre for Emergency Medicine, Department of Clinical Medicine , Aarhus University Hospital, Aarhus, Denmark. d Department of Public Health, Aarhus University, Aarhus, Denmark. e Centre of Research in Rehabilitation (CORIR), Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark.

f DEFACTUM, Central Denmark Region, Aarhus, Denmark g Department of Health Science and Technology, Aalborg University, Aalborg, Denmark.

Correspondance: Louise Moeldrup Nielsen, VIA University College, Hedeager 2, 8200 Arhus N, Denmark, Tel: +45 5124 5081, Email: [email protected]

Returning to everyday life after discharge from a short-stay unit at the Emergency Department– a qualitative study of elderly patients’ experiences

Abstract Elderly patients often receive care and rehabilitation from different providers across healthcare settings, due to the complexity of their health condition. Collaboration between hospital and primary care providers are therefore essential to ensure that the discharge and transition of rehabilitation is coherent. However, research that focuses on elderly patient’s experiences of the discharge and their everyday lives after, has attracted little attention. This study explores elderly patients’ experiences of being discharged and returning to everyday lives after discharge from a short-stay unit at the emergency department. Eleven qualitative interviews with elderly patients were conducted two weeks after their discharge. The transcribed interviews were analyzed using systematic text condensation. The study identified four themes: "Pain and fatigue limited performance of daily activities", "Frustrations and concerns", "The importance of being involved and listened to during admission" and "The importance of being prepared for being discharged". In the participants perspective it was difficult, due to fatigue and pain, to perform daily activities after discharge. Participants who experienced not being prepared and clarified in relation to their discharge, continued to have several concerns for the future. They also experienced some challenges related to lack of being involved in the discharge and lack of receiving the information needed. The identified factors may be relevant to address in order to ensure a coherent discharge and return to everyday life for elderly patients after discharge form a short-stay unit at the emergency department.

Keywords: Elderly patients, transition, rehabilitation, everyday life, discharge, daily activities, patient perspective, emergency care.

Introduction Elderly patients are especially vulnerable when they are being discharged from hospital to home due to the complexity of their health problems (Grimmer et al., 2013; Rydeman & Tornkvist, 2006). They are at high risk of readmission, with up to 20% being readmitted within 30 days after discharge (McCabe, 2015; Salvi et al., 2007). After discharge, elderly patients need to cope with changes in their everyday lives due to their health condition as well as decreased ability to perform daily activities (Jonsson, Appelros, & Fredriksson, 2017; McCabe, 2015; McKeown, 2007).

Elderly patients’ health problems are often more complex than those of younger patients with respect to comorbidity and limitation in performing daily activities (McCabe, 2015). Due to the complexity of their health problems, elderly patients typically receive care and rehabilitation from different providers across multiple healthcare settings after discharge. Effective collaboration between hospital and primary care providers are therefore essential to ensure that the discharge and transition of rehabilitation is coherent (Goncalves-Bradley, Lannin, Clemson, Cameron, & Shepperd, 2016; Hesselink, Schoonhoven, Plas, Wollersheim, & Vernooij-Dassen, 2013; Slatyer et al., 2013). A coherent discharge is characterised by collaboration between healthcare sectors with a high level of continuity and coordination, and with a clear distribution of responsibilities supported by consistent information pathways (Danish Health and Medicine Authority, 2016).

Discharging elderly patients and transitioning their rehabilitation from hospital to primary care are focal points of studies aimed at reducing risks of hospital readmission amongst the elderly patients’ (Goncalves-Bradley et al., 2016; Karam, Radden, Berall, Cheng, & Gruneir, 2015; Lowthian, McGinnes, Brand, Barker, & Cameron, 2015). However, research that focuses on patient-perceived factors has attracted little attention. A study from 2015 revealed that frail, elderly patients experienced the transition to home as unsafe and troublesome and that their everyday lives were affected one week after discharge (Andreasen, Lund, Aadahl, & Sorensen, 2015). Another study from 2015 revealed that elderly patients experienced lack of information and participation in the discharge process (Hvalvik & Dale, 2015). Important elements in feeling prepared to come home after discharge were described by elderly patients and their relatives in a study from 2010 (Rydeman & Tornkvist, 2010). The elderly patients in that study felt prepared to come home if information and arrangements about care issues, daily activities and contacts were organised (Rydeman & Tornkvist, 2010).

Although a number of studies have examined elderly patients’ experiences of being discharged and how they perceive their everyday lives after hospitalisation, none of the identified studies were based on elderly patients’ discharge after a brief hospitalisation from a short-stay unit at the Emergency Department (ED). Discharge from a short-stay unit at the ED may be especially challenging for elderly patients due to the short admission time and the short time to prepare and coordinate the discharge and the transition of rehabilitation to primary care. To address potential issues of importance for a coherent discharge and transition of rehabilitation from a short-stay unit at the ED to primary care, further examination of elderly patients’ perspectives is required. Elderly patients experiences of the discharge and the everyday lives after, may contribute with important knowledge to improve the quality of discharges. The aim of this study was to explore and gain deeper understanding of elderly patients` experiences of being discharged and return to everyday lives after discharge from a short-stay unit the ED.

Methods In order to gain insight into elderly patients` experiences of being discharged and return to everyday lives after discharge, a qualitative research design involving semi-structured interviews was chosen. Individual interviews were conducted in order to gather rich descriptions of elderly patients’ experiences and to increase our understanding of the phenomenon. The study was guided by Giorgi’s methodological descriptive approach which is based on the phenomenological philosophy of Husserl to provide an understanding of the phenomena of interest based on lived experiences (Giorgi, 1997; Giorgi, 2005; Sadala, 2002; Schiermer B, 2013). The experience of being discharged and returning to everyday life is a subjective phenomenon that is experienced individually and phenomenology emphasizes subjectivity. Thus a phenomenology approach guided the study to grant access to the individuals experience of the everyday life after discharge as it is perceived by the subject (Giorgi, 2005; Schiermer, 2013). According to the descriptive phenomenological approach, lived experience should not necessarily be interpreted, but can be described and understood in terms of how people perceive them and not from a theoretical standpoint (Bevan, 2014; Giorgi, 1997; Giorgi, 2005; Tuohy, Cooney, Dowling, Murphy, Sixmith, 2013).

Participants and study setting The study setting was the participants’ own homes where the interviews were conducted two weeks after the participants had been discharged from a short stay unit at the ED. The qualitative study took place alongside a quasi-experimental study that was conducted at the ED of a 1150-bed university hospital in the central region of Denmark. The purpose of the experimental study was to examine the effectiveness of an intervention aimed at reducing risk of readmission for elderly patients. 144 elderly patients were allocated to receive the intervention and 231 patients to receive usual practice. Briefly, the intervention consisted of assessment of elderly patients’ performance of daily activities at the short-stay unit at the ED, referral to further rehabilitation in primary care and a follow-up at home visit the day after discharge. A detailed description of the study is reported elsewhere (Nielsen et al., 2018) Participants in the interviews were recruited among those patients who had experienced the intervention in the experimental study. The inclusion criteria were acutely admitted elderly patients over 65 years old, discharged directly to their own home from a short stay unit at the ED and living in a larger municipality in Denmark (335.000 inhabitants). Exclusion criteria were terminal illness, severe dementia or being unable to speak and understand Danish. Purposive sampling was adopted to ensure variation in characteristics such as diagnosis, gender, age and homecare services. This was done in order to ensure sufficient data richness (Creswell, 2013; Kvale & Brinkmann, 2015). Recruitment took place from November to December 2014. Shortly before discharge, elderly patients (n=15) were invited to participate and were given written information about the purpose of the study. Thirteen gave their consent to be contacted after discharge. Approximately one week after discharge, the patients were contacted by phone by the first author and informed about the aim of the study, that it was voluntary and the duration of the interview. Eleven elderly patients gave their informed consent to participate: three men and eight women (Table 1). Two patients out of the thirteen asked, chose not to participate due to their poor medical condition. Written consent to participate was obtained from the 11 participants on the day of the interviews.

Table 1: Charateristics of the study participants (n=11)

Participant Gender Age Civil status Reason for Length of Recieving admission admission Home care A Female 83 Living alone Back pain 2 days + B Male 70 Living alone Infection 1 day - C Female 86 Living alone Respiratory 2 days + D Female 76 Living with partner Neurological 1 day - E Male 65 Living alone Neurological 1 day + F Female 83 Living alone Infection 2 days - G Female 73 Living alone Respiratory 1 day - H Female 67 Living alone Heart problems 1 day + I Female 67 Living alone Infection 1 day - J Female 76 Living with partner Neurological 1 day + K Male 76 Living with partner Neurological 1 day -

Data collection Individual interviews that lasted between 30-60 minutes were conducted by the first author. In line with the phenomenological approach and the aim of the study, both open-ended and flexible questions was used to invited participants to describe their discharge, how they experienced returning to their everyday lives and receiving rehabilitation service (Table 2). The interview guide served as a guide to help stay focused on the themes, preventing unfocussed interviewing but at the same time invite participants to describe their subjective experiences as it occur in their everyday lives after discharge. The use of open-ended questions aimed to get the participants to describe the specific situations and actions as it occur in their everyday lives, not their general opinions about the phenomenon. After a presentation of the interviewer and a short briefing, the participants were invited to talk freely and in detail about their experiences, and both positive and negative aspects were explored. Prompts such as "Could you give an example of this" or "Could you tell me more about that" were used to encourage the participants to tell more (Englander, 2012; Kvale & Brinkmann, 2015; Starks, 2007). As a phenomenological approach was used to guide both the data collectation and the analysis, the first author attempt to bracket her preconception about the phenomenon to understand it as experienced by the participants (Giorgi, 2005). To maintain an open and flexible attitude during interviews, interview questions were discussed and reflected upon by the first and last author and

6 preconecptions was written down before conducting any of the interviews (Bevan, 2014). All of the interviews were audiotaped and transcribed verbatim by the first author and a research assistant.

Table 2: Interview guide

Main theme Questions At the hospital Please try to explain how you experienced being admitted to hospital. During your hospital stay, did anybody talk to you about how you manage different tasks at home? Discharge Please describe the discharge from hospital and how you experienced this. Getting home What was it like to come home again after hospital admission? What was important to you after you came home from the hospital? Please try to describe to me how you manage your everyday life at home. Rehabilitation How do you experience being offered to participate in rehabilitation?

Data analysis Malterud’s modification of Giorgi’s phenomenological approach to systematic text condensation was used in the analysis. This approach focuses on patterns and variations in the data, leading to a description of the participants’ experiences (Malterud, 2001; Malterud, 2011; Malterud, 2012). In accordance with a descriptive phenomenological methodology, an inductive approach was present in the analysis phase, as we wanted the aspects from the elderly patient's experiences to shape the themes and codes, not theory or other preconceptions (Giorgi, 1997). The analysis followed the steps: 1) Forming an overall impression, 2) Identifying and sorting meaning units, 3) Condensation and 4) Synthesising the codes into descriptions (Malterud, 2001; Malterud, 2011; Malterud, 2012). Following these steps, the first author listened to all of the interviews and read the transcripts as a whole several times to gain an overview of the total content. In step 1, preliminary themes were identified and discussed with the last author. In step 2, meaning units containing information that related to the preliminary themes were identified and coded using different colours. In step 3, data were reduced and condensed to a decontextualised selection of meaning units and sorted into

7 thematic sub-codes across the participants using a matrix. In the condensing process, the focus was on maintaining the original terminology as much as possible. Finally, the condensed meaning units were synthesised into descriptions that related to each theme and subtheme. The descriptions were discussed with the last author and four themes were agreed upon. Meaningful quotations describing the content of the subthemes were added in the description. The quotations demonstrate both similarities and differences in how the participants experienced returning to their everyday lives and how they experienced being discharged. The four main themes and subthemes are presented in Table 3; they are accompanied by illustrative quotes to ensure transparency. Moving between the four steps was done iteratively, from the overall impression to particular parts of the transcript, identifying themes and subthemes of importance from the elderly patients’ perspective (Malterud, 2012).

Table 3. Themes and subthemes with corresponding quotes

Theme Subtheme Golden qoutes Pain and fatigue Adapting daily activities "That's what irritates me, I get tired too early. I am not used to that – to limited performance because of fatigue being tired" (J, line 444) of daily activities Pain that limits "I try to keep it (pain) down with painkillers and by walking around and moving and so on. But now I've not been moving around much because I've been feeling bad – it's a vicious circle alright" (F, lines 321-323)

Uncertainty concerning "But it's very overwhelming, all those things that are going to happen - rehabilitation so you're going to have rehabilitation? yes, I am and then I don't really say anything else" (H, lines 382-383)

Frustrations and Uncertainty characterizes "Most of it is the psychological part – why has this happened and can it concerns everyday life happen again, and does it mean that I should not be alone too much? Does this mean that I should not go skiing anymore - I've done this alone because my wife is not skiing. But should I stop that because something could happen?" (K, lines 184-187)

The time while waiting "It (the health condition) comes back every time, I think. Now, I hope that they will figure something out soon. The doctor was not sure and she said "before you have a diagnosis I cannot begin to treat you", and she could not find a diagnosis" (F, lines 278-281)

The importance of The Health professionals "And he admitted me to the hospital and that was also okay. But if they being involved and had all known what they should know, right...... and it's often the case listened to during with doctors - A doesn’t know what B has said" (J, lines 92-93) admission Participation in Medical "I talked to a doctor, but it was in the evening the first day; actually, it review was about 23:30 in the evening - I was simply so tired, I had been up before 6 and had slept badly the night before .... There were some things I was asked about that I really didn't get around. I see that, I really see that today" (G, lines 29-32)

The importance of Being discharged "Well, I did not feel so good about it (being discharged), because I was being prepared for still in pain and all and I thought that it was a waste of time that I had being discharged come (to the hospital)" (A, lines 150- 151)

Information "It would be nice to get something in writing. That's always nice, so you can return to it. You can't do that when it is oral. That's what I say, you should be two instead of one. But if you are alone, you can get in doubt about what it was. It is very different if you get it in writing – then you can go back" (G, lines 316 to 319)

Ethical considerations

The participants in the study were elderly patients, some of which had servere disabilities. This called for special considerations in the interview situation were the interviewer tried to be attentive to the participants situation by trying to create a relaxed atmosphere and adjusting the length of the interview and not pressuring sensitive questions. The study was approved by the Danish Data

Protection Agency (J.nr. 2012-41-0763). Basic principles for research according to the Helsinki Declaration were followed (World Medical Association, 2017). All participants were given written and oral information about the study, and written informed consent was obtained from all of the participants. Anonymity and confidentiality were secured, and participants were informed that they could withdraw from the study at any time without there being any consequences for present or future health services.

Findings Four themes emerged as central to the participants’ experience of return to their everyday lives and their experiences of being discharged: "Pain and fatigue limited performance of daily activities", "Frustrations and concerns", "The importance of being involved and listened to during admission" and "The importance of being prepared for being discharged" (Table 3).

Pain and fatigue limited performance of daily activities Since discharge, the participants experienced their everyday lives as being marked by fatigue, lack of energy and pain, all of which limited their performance of daily activities. Fatigue and lack of energy made it more difficult to perform activities than before admission, which led to some of them feeling irritated about not being able to manage the activities. Before admission some of the participants received help to perform domestic tasks and after their discharge, some of them experienced need for either more help or receiving help more often. Sometimes, the participants were able to adapt to their changes by dividing an activity into smaller tasks that could be carried out over several days or by using assistive devices. In other cases, resting in the middle of the day could help provide the energy needed to get through the afternoon and evening.

"That's what irritates me, I get tired too early. I am not used to that – to being tired" (J, line 444)

Pain was experienced as a limitation on performing daily activities. Due to pain, it was difficult for some of the participants to be as mobile as they had been previously, which meant that they did not get outside their home. Despite the fact that they considered it important to get outside, pain reduced the possibility of doing so, or made it impossible.

"I try to keep it (pain) down with painkillers and by walking around and moving and so on. But now I've not been moving around much because I've been feeling bad – it's a vicious circle alright" (F, lines 321-323)

Participants’ expectations for rehabilitation after discharge were mostly positive as they expected to be able to perform daily activities as they used to before they were admitted to the ED. For participants not receiving a clear diagnosis while being admitted, thoughts of further rehabilitation were difficult to manage. Participants were concerned about their health situation and how they should handle further examinations. The uncertainty they experienced about how rehabilitation should be organised was related to whether they could continue with the specific rehabilitation training they received prior to admission and for how long. Being able to receive rehabilitation in once own home was considered important. Some participants stated that it could be difficult to leave home, particularly in the mornings where tiredness was prominent. It could also feel overwhelming if participants had to relate to a new therapist.

"But it's very overwhelming, all those things that are going to happen - so you're going to have rehabilitation? yes, I am and then I don't really say anything else" (H, lines 382-383)

Participants experienced that their everyday lives had changed after discharge, and that fatigue and pain affected their performance of daily activities, making adaptation necessary.

Frustrations and concerns Participants experienced frustration and concerns after being discharged. Lack of clarification as to what led to their admission created concerns that affected their everyday lives. Concerns about what caused the admission meant that some speculated on how their lives would look in the long term. Participants were also concerned about whether they would be able to perform their daily activities in the long term but at the same time, performing small daily tasks, like hanging up the laundry, could feel unimportant for some. Participant K, a 76 old man was concerned about whether he and his wife would be able to travel abroad as they have done previously.

"Most of it is the psychological part – why has this happened and can it happen again, and does it mean that I should not be alone too much? Does this mean that I should not go skiing anymore - I've done this alone because my wife is not skiing. But should I stop that because something could happen?" (K, lines 184-187)

The time spent waiting for further examinations was experienced as long and difficult with many concerns such as experiencing the condition getting worse and having less energy. Participant F explained that in her case, an actual treatment could not begin until there was clarity about the diagnosis. "It (the health condition) comes back every time, I think. Now, I hope that they will figure something out soon. The doctor was not sure and she said "before you have a diagnosis I cannot begin to treat you", and she could not find a diagnosis" (F, lines 278-281)

Some of the participants also expressed confusion about lack of clear information about which further examinations that were planned. One of the participants experienced that he did not receive the help he needed and asked for. Another participant also experienced difficulties, but related it to severeal different health professionals, involved in her situation.

The importance of being involved and listened to during admission Overall, the participants experienced being treated well during admission, but they stressed that there was a hectic atmosphere with a high turnover of health professionals. Participants emphasised that it was important to be involved in decision-making and be listened to during admission, especially during the medical interview. Some experienced that the various doctors did not know what each other had said or done. Furthermore, there was waiting time to see the doctors, and it was hard to establish what was going on because the health professionals had different views related to the patients situation. "And he admitted me to the hospital and that was also okay. But if they had all known what they should know, right...... and it's often the case with doctors - A doesn’t know what B has said" (J, lines 92-93)

The experience of not being listened to could make participants feel uninvolved in the discharge process. They found that although some physicians were good at informing about further actions and examinations, they were sometimes too busy to ask about how the participants thought and felt about the situation. Sometimes medical reviews took place late at night, which meant that the patient was too tired to ask questions about their condition or situation. This could lead to several unresolved issues in relation to discharge.

"I talked to a doctor, but it was in the evening the first day; actually, it was about 23:30 in the evening - I was simply so tired, I had been up before 6 and had slept badly the night before .... There were some things I was asked about that I really didn't get around. I see that, I really see that today" (G, lines 29-32)

Some of the participants experienced waiting time during admission and that it was difficult to find out what was going on. One of the participants experienced lack of information from the healthcare staff, as they had packed her personal stuff together before she knew she were being discharged.

The importance of being prepared for being discharged Participants found that it was important to be prepared before discharge. They were all discharged 1-2 days after admission, which for several of them came as a surprise as they did not feel ready. Not everyone agreed with the decision about being discharged, and some felt that they had not been involved in the decision. It felt like a waste of time to be admitted when the condition did not change for the better, and they might as well have been at home in their familiar environment. Participant A, a 83 year old woman, did not understand why she was being discharged when she was still in pain. "Well, I did not feel so good about it (being discharged), because I was still in pain and all and I thought that it was a waste of time that I had come (to the hospital)" (A, lines 150- 151)

Central to the participants’ experiences of a positive discharge was feeling secure about returning home. Participants who lived with a spouse experienced a sense of security, as there was someone to care of them after discharge.

Information about what was going to happen was deemed important by participants in relation to the quality of their discharge. For instance, were there going to be further examinations, rehabilitation, or care? Some of the participants experienced that they got the verbal and written information they needed in relation to their discharge, while others experienced they did not and expressed a wish for more relevant information. One of the informants experienced that lack of information about her medical treatment was problematic, because the general practioner was not aware that she has changed medication. Furthermore, the written information could be difficult to relate to, as it was difficult to understand, and the material needed further clarification.

"It would be nice to get something in writing. That's always nice, so you can return to it. You can't do that when it is oral. That's what I say, you should be two instead of one. But if you are alone, you can get in doubt about what it was. It is very different if you get it in writing – then you can go back" (G, lines 316 to 319)

Discussion With regard to being discharged from a short-stay unit at the ED, different factors, revealed in four themes, were considered by the participants to be important for their everyday lives after being discharged. Fatigue and pain, affected participants’ performance of daily activities, 14 days after their discharge. Although it is possible to let caregivers take over some of the participants’ daily activities, such as housekeeping tasks, the participants expressed dissatisfaction with not being able to perform these activities themselves. Some explained how they were able to handle their decreased ability to perform daily activities by using adaptation strategies, such as dividing activities into smaller tasks, while others abstained from performing these activities. Using different strategies to adapt to new situations is well-known from other studies (Aberg, Sidenvall, Hepworth, O'Reilly, & Lithell, 2005; Neiterman, Wodchis, & Bourgeault, 2015; Zakrajsek, Schuster, Guenther, & Lorentz, 2013). A study from 2005 revealed that elderly patients adopt different adaptation strategies in their everyday lives to avoid negative experiences due to their health condition (Aberg et al., 2005). The ability to continue with daily activities that are meaningful in their everyday lives is important, and different strategies can be used to reduce the gap between

14 decreased capacity and the demands of the environment (Kielhofner, 2008). The participants in our study were in an ongoing process of learning to use adaptation strategies to perform daily activities and changing roles, habits and routines, although some of them were challenged in that process. Their expectations for rehabilitation after discharge were mostly positive as they expected to be able to perform daily activities as they used to before they were admitted to the short-stay unit at the ED. This is in line with other studies which suggest that elderly patients admitted for acute illness should be targeted for rehabilitative services after discharge (Boyd, Landefeld, Counsell, Palmer, Fortinsky, et al, 2008; Goncalves-Bradley et al., 2016)

The participants’ everyday lives were also influenced by thoughts about their health condition as well as concerns for the future. Participants who experienced not being prepared or who did not have their diagnosis clarified felt frustrated and had concerns about whether they would be able to perform daily activities in the long term or if they would experience loss of activities. Uncertainty about their health condition and whether they should avoid performing daily activities may lead to a vicious spiral. If elderly patients avoid performing daily activities because of uncertainty, this may, in turn, decrease their ability to perform daily activities (Larsson, Ekvall Hansson, Sundquist, & Jakobsson, 2016; Mackichan, Adamson, & Gooberman-Hill, 2013). Our findings about elderly patients’ concerns is in accordance with the findings of another study where elderly patients were concerned about how to handle their life situation after being discharged (Rydeman & Tornkvist, 2010). Our study, however, showed that especially participants who did not have a clear diagnosis felt unprepared to return home and were concerned about the impact of their health condition on their everyday lives. It is important to take these new findings into consideration in clinical practice and doing so may lead to the development of improved informational material about what is going to happen in relation to clarifying further the elderly patients’ condition. Moreover, provision of clear information about whether there are restrictions on certain activities may contribute to preventing decreased ability to performing daily activities and should be an important element in the discharge process.

The results of the present study show that elderly patients want to be involved and participate in their discharge from the ED, although lack of verbal and written information and lack of involvement in the discharge process were experienced by some of the participants. Not everyone agreed with the doctors’ decision about the time of discharge, and some did not feel that they had

15 been involved in the decision. Other studies support this finding (Hvalvik & Dale, 2015; Naylor, 2002). In a study from 2015, participants reported feeling invisible in the discharge process due to lack of involvement and communication with health professionals (Hvalvik & Dale, 2015). Providing sufficient information about further clarification, treatment and rehabilitation and allowing patients to describe their perceived health challenges are necessary to involve elderly patients in decision-making and for truly informed choice (Dyrstad, Testad, & Storm, 2015).

Methodological considerations A strength of this study is that the qualitative individual interviews were conducted in a natural setting (e.g. the participants own home) to explore the complex phenomenon of elderly patients returning to their everyday lives after discharge from a short stay unit at the ED and how they experience being discharged. The home environment can facilitate more comfortable relationships between the researcher and participant and may encourage the particpants to talk more freely during the interview (Sivell et al., 2015). The use of af phenomenological methodological approach for guiding both the collection and analysis of data was suitable for examining patients’ experiences of returning to their everyday lives, although it posed challenges in relation to the participants way of expressing themselves. The participants’ ability to express themselves and describe their experiences varied and great efforts was devoted to give the participants every possibilities to expres all their perceptions by using open- ended questions. A broad variation of participants e.g. gender, age and diagnosis was included to provide nuanced insights into the elderly patients’ experiences; and extensive interviews were conducted. The participants provided rich and varied data to a degree that ensured a qualified answer to the aim of the study. When using a phenomenological methodological approach, researchers face the challenge of not letting preconceptions influence the interviewing or the findings. The researcher conducted interviews and analysis with as few preconceptions as possible. The first author primarily carried out the interviews and the analysis, and was supervised by the last author. Preconceptions were continuously reflected upon in order to achieve trustworthy findings and ensure transparency. Before conducting the interviews, the researchers had a preconception that the transition between hospital and primary care would be challenging for the participants. However, none of the participants expressed opinions on the transition; rather, they described the challenges of returning

16 to their everyday lives. The use of a phenomenological approach allowed the researcher to pursue what was important for the participants, rather than seeking answers to predefined questions. The use of systematic textcondensation as a method for analysing data were found highly relevant as the method helped the researchers to stay focused on the participants experiences without the use of theory. This resulted in descriptions that provide insights into the elderly patients’ experiences of returning to their everyday lives and how they experience being discharged. These insights may help to improve the quality of transition from hospital to primary care for elderly patients in the furture.

A limitation in this study was that it was conducted in a single hospital with recruitment of partipants who had been involved in a clinical trial and received a specific intervention. Accordingly, we have provided a detail description of the setting and the intervention to enhance the transferability of findings to other similar settings. Voluntary participation might also have yielded a sample that held strong views about the discharge process which may affect the transferability of the findings. The results cannot be transferred to all elderly patients, but can be seen as illuminating patterns that can be used for hypothesis generation in further studies.

Conclusion Our study revealed that factors such as decreased ability to perform daily activities, not having their diagnosis clarified and not being prepared and involved in the discharge process was important for the elderly patients’ discharge from the ED and their everyday lives after discharge. These findings contribute with important knowledge about elderly patients’ experiences and concerns, and these experiences and concerns should be taken into consideration by health professionals who plan the discharge process and refers patients to further rehabilitation. Further research is needed to examine how the process of discharge may be improved and how focus on elderly patients’ everyday lives and their performance of daily activities can be included both at hospital and in primary care.

Acknowledgement

We thank the study participants for their participation and valuable contributions.

Disclosure statement No potential conflict of interest was reported by the authors.

Funding

This study was funded by Tryg Foundation [grant number 107632], Foundation of Public Health in the Middle [grant number 1-30-72-141-12]and Aase and Ejnar Danielsen’s foundation [grant number 10-001233]. The foundations played no role in the design, execution, analysis and interpretation of data, or writing of the study.

Notes on contributors Louise Moeldrup Nielsen is a PhD-student at the Department of Physiotherapy and Occupational therapy and Research Center for Emergency Medicine, Aarhus University Hospital. She is also Associate Professor at the Department of Occupational Therapy at VIA University College, Denmark.

Lisa Gregersen Oestergaard is Assistant Professor at the Department of Physiotherapy and Occupational therapy, Centre of Research in Rehabilitation (CORIR), Department of Clinical Medicine, Aarhus University and Aarhus University Hospital and Department of Public Health, Aarhus University, Denmark.

Thomas Maribo is senior researcher at DEFACTUM, Public Health and Quality Improvement, Central Denmark Region. He is also an Associate Professor at the Department of Public Health

Aarhus University, Denmark.

Hans Kirkegaard is Professor and Research Manager at Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University Hospital, Denmark

Kirsten Schultz Petersen is Associate Professor at the Department of Health Science and Technology, Aalborg University, Denmark

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11. Appendices

Appendix A Search strategy and search string for effectiveness studies

Appendix B Assessment of risk of bias of effectiveness studies

Appendix C Search strategy and search string for occupational therapy studies

Appendix D Assessment of risk of bias of occupational therapy studies

Appendix E Search strategy for assessment measures

140

Appendix A Appendix A: Search strategy and search string for effectiveness studies

Search question: What characterizes interventions aimed at reducing risk of readmission in elderly patients discharged from an acute or emergency department?

Inclusion criteria: P: Age 65+ I: Discharge interventions aimed at reducing risk of readmission C: No explicit criteria O: Readmission, stated as primary outcome (c): Acute setting

Exclusion criteria: P: Diagnosis specific studies (one single diagnosis, e.g. stroke, dementia, cancer)

Table 1a. Search strategy Keyword Keyword 1 Keyword 2 Population Older (A1)* Elderly (A2)*

Intervention Discharge (B1)

Comparator

Outcome Readmission (C1) Re visit (C2) Rehospitalisation (C3)

context Emergency Department (D1) Acute (D2) *The keywords older and elderly were only used in Cochrane as no age limits exicist.

Table 2a. Search string Database Search string Hits (Limits) Embase #1: B1 5.234 Age 65+ #2: C1 OR C2 OR C3 1.196 Metaanalysis #3: D1 OR D2 25.371 Systematic reviews #4: #1 AND #2 AND #3 233 Clinical trials

Pubmed #1: B1 6.142 Age 65+ #2: C1 OR C2 OR C3 1.213 Clinical trials #3: D1 OR D2 40.057 Reviews #4: #1 AND #2 AND #3 200

Cinahl #1: B1 367 Age 65+ #2: C1 OR C2 OR C3 108 Clinical trials #3: D1 OR D2 1210 #4: #1 AND #2 AND #3 19

Cochrane #1:A1 OR A2 97.192 Trials #1: B1 65.041 #2: C1 OR C2 OR C3 18.512 #3: D1 OR D2 3.937 #5: #1 AND #2 AND #3 AND #4 226

Appendix B Table 3a. Risk of bias assessment for intervention studies aimed at reducing risk of readmission in elderly patients discharged from an emergency department.

Selection bias Performance bias Detection bias Attrition bias Reporting bias Random Sequence Allocation Study Generation concealment Caplan et al - - ? - - ? (87) Computerized Allocation was No information about Objective measure of Outcome reported Not able to judge from randomization concealed personnel or patient primary outcome for all patients available information blinding (blinding) Cossette et - - ? - ? al (88) Computerized Central allocation No information about Objective measure of An interim analysis Not able to judge from randomization personnel or patient primary outcome stopped inclusion available information blinding (blinding) Courtney et - - ? - + - al (89) Computerized Central allocation Not able to judge due to Objective measure of Missing outcome All pre-specified out- randomization insufficient information primary outcome likely to be related comes are reported (blinding) to outcome Dedhia et al + + ? - - ? (90) Non-randomized Non-randomized Not able to judge due to Objective measure of Outcome reported Not able to judge from Pre/post design insufficient information primary outcome for all patients available information (blinding) Guttman et + + ? - - ? al (91) Non-randomized Non-randomized Not able to judge due to Outcome verified through Outcome reported Not able to judge from Pre/post design insufficient information database (blinding) for all patients available information Legrain et - - ? - - ? al (92) Computerized Central allocation Not able to judge due to Objective measure of Outcome reported Not able to judge from randomization insufficient information primary outcome for all patients available information (blinding) Mion et al - - ? - - ? (93) Computerized Central allocation Not able to judge due to Objective measure of Outcome reported Not able to judge from randomization insufficient information primary outcome for all patients available information (blinding) Pedersen et + + ? - - ? al (94) Non-randomized Non-randomized No information about Objective measure of Outcome reported Not able to judge from Quasi design personnel or patient primary outcome for all patients available information blinding (blinding) Rosted et al - - ? - - ? (95) Computerized Allocation was No information about Objective measure of Outcome reported Not able to judge from randomization concealed personnel or patient primary outcome for all patients available information blinding (blinding) Note. Categories for risk of bias: + = High risk of bias, - = Low risk of bias ? = Unclear if there is risk of bias.

Appendix C Appendix C: Search strategy and search string for occupational theraphy interventions

Search question: What characterizes interventions that are effective at enhancing performance of daily activties in older people

Inclusion criteria: P: Age 65+ I: Interventions aimed at enhancing the performance of daily activities C: No explicit criteria O: Quantitatively measured between group differences assessed with validated instruments.

Exclusion criteria: P: Diagnosis specific studies (one single diagnosis, e.g. stroke, dementia, cancer) I: Main focus on falls prevention, focus on driving a car, group-based interventions

Table 4a. Search strategy PICO Keyword 1 Keyword 2 Keyword 3 Keyword 4 Keyword 5 Population*:

Intervention: Occupational Enablement Accessibility Therapy (B1) (B2) (B3) Comparator:

Outcome: Occupation Activit* Daily living Everyday life ADL (C1) (C2) (C3) (C4) (C5)

*No keywords was used for the population, only limits were used in the searches

Table 5a. Search string Database Search string Hits Included (Limits) Pubmed #1: B1 OR B2 OR B3 1.447 De Coninck/ Clemson/ Age 65+ #2: C1 OR C2 OR C3 OR C4 OR C5 38.512 Whitehead/ Tuntland/ Meta-analysis #3: #1 AND #2 557 Sturkenboom/ Gitlin/ Systematic reviews Orellano/ Lannin/ Clinical trials Abizanda/ Wressle/ Steultjens/Nielsen

Embase #1: B1 OR B2 OR B3 1.145 Stark/Clemson/Whitehead/ Age 65+ #2: C1 OR C2 OR C3 OR C4 OR C5 33.476 DeVrindt/ Tuntland/ Clinical trials #3: #1 AND #2 472 Abizanda/Gitlin/ Lannin/ Controlled clinical Shearer trials RCT

Cinahl #1: B1 OR B2 OR B3 237 Clemson/Abizanda Age 65+ #2: C1 OR C2 OR C3 OR C4 OR C5 3.282 RCT #3: #1 AND #2 100

Appendix D Table 6a. Risk of bias assessment for occupational therapy interventions aimed at enhancing the performance of daily activities in older people

Study Selection bias Performance bias Detection bias Attrition bias Reporting bias Random Sequence Allocation concealment Generation Abizanda - ? - - ? ? et al (105) Computerized Not able to judge from Study personnel not Outcome assessor No reason for missing Not able to judge from randomization available information delivering OT blinded, not blinded data provided available information patients Clemson - - ? - + - et al (106) Computerized Central allocation Not able to judge due to Outcome assessor Missing outcome for All pre-specified out- randomization insufficient information blinded 15% of participants comes are reported DeVrindt - ? ? - - ? et al (107) Computerized Not able to judge from Not able to judge due to Outcome assessor Missing outcome for Not able to judge from randomization available information insufficient information blinded only 6 % of available information participants Gitlin et al - ? ? + + ? (108) Computerized block Not able to judge from Not able to judge due to No information about Missing outcome for Not able to judge from randomization available information insufficient information assessor blinding 11% of participants available information and differences Lannin et - ? ? + ? - al (109) Computerized Not able to judge from No information about No information about No reason for missing All pre-specified out- randomization available information blinding assessor blinding data provided comes are reported Nielsen et - - ? - + - al (110) Computerized block Central allocation No information about Outcome assessor Missing outcome for All pre-specified out- randomization blinding blinded 25% and 18% comes are reported Shearer et + + ? + - ? al (111) Non-randomized Non-randomized Not able to judge due to No information about Outcome reported for Not able to judge from Pre/post design insufficient information assessor blinding all patients available information Tuntland - - ? - + - et al (112) Computerized block Central allocation No information about Outcome assessor Missing outcome for All pre-specified out- randomization blinding blinded 16% of participants comes are reported Whitehead - - ? - + - et al (113) Computerized Central allocation Not able to judge due to Outcome assessor Missing outcome for All pre-specified out- randomization insufficient information blinded 27 % of participants comes are reported Wressle et + + ? + + ? al (114) Randomization based Allocation by a nurse at No information about No information about Missing outcome for Not able to judge from on admission time the department blinding assessor blinding 19% of participants available information Note. Categories for risk of bias: + = High risk of bias, - = Low risk of bias, ? = Unclear if there is risk of bias

Appendix E Appendix E: Search strategy and search string for assessments measures

Search question: Which performance-based assessements are validated in older people (65+)?

Inclusion criteria: Original peer reviewed articles Performance-based assessment measures Validated in a older population (65+)

Exclusion citeria: Diagnosis specific assessments

Table 7a. Search strategy Keyword Keyword 1 Keyword 2 Keyword 3 Keyword 4 Keyword 5 Functioning (A) Functional Functional status Functional Activities of Occupational outcome (A1) (A2) ability daily living performance (A3) (A4) (A5)

Assessment (B) Tool (B1) Instrument (B2) Test (B3)

Validity (C) Reliability (C1)

Table 8a. Search string Database Search string Hits

Embase #1: A OR A1 OR A2 OR A3 OR A4 50.132 Limits: Age 65+ #2: B OR B1 OR B2 OR B3 472.310 #3: C OR C1 18.544 #4: #1 AND #2 AND #3 1.331

Pubmed #1: A OR A1 OR A2 OR A3 OR A4 OR A5 55.856 Limits:Age 65+ #2: B OR B1 OR B2 OR B3 439.795 #3: C OR C1 29.846 #4: #1 AND #2 AND #3 2.884

Cinahl #1: A OR A1 OR A2 OR A3 OR A4 19.514 Limits: Age 65+ #2: B OR B1 OR B2 OR B3 104.410 #3: C OR C1 15.700 #4: #1 AND #2 AND #3 2.299