Barriers and Facilitators of a Community-Based, Slow-Stream Rehabilitation, Hospital-to-Home Transition Program for Older Adults: Perspectives of a Multidisciplinary Care Team

The purpose of this study was to examine the perspectives of support staff, health care professionals, and care coordinators working in or referring to a community-based, slow-stream rehabilitation, hospital-to-home transition program regarding gaps in services, and barriers and facilitators related to implementation and functioning of the program. This was a qualitative descriptive study. Recruitment was conducted through purposive sampling, and 23 individuals participated in a focus groups or individual semi-structured interview. Transcripts were analyzed by six researchers using inductive thematic analysis. Themes that emerged were organized based on a socio-ecological framework. Themes were categorized as: (1) macro level, meaning gaps while waiting for program, limited program capacity, and gaps in service post-program completion; (2) meso level, meaning lack of knowledge and awareness of the program, lack of specific referral process and procedures, lack of specific eligibility criteria, and need for enhanced communication among care settings; or (3) micro level, meaning services provided, program participant benefits, person-centred communication, program structure constraints, need for use of outcome measures, and follow-up or lack of follow-up. Implementation of seamless patient information sharing, documentation, use of specific referral criteria, and use of standardized outcome measures may reduce the number of unsuitable referrals and provide useful information for referral and program staff. L'objectif de cette etude etait d'examiner les points de vue du personnel de soutien, des professionnels de la sante et des coordonnateurs de soins qui recommandent des patients ou collaborent a un programme communautaire de transition de l'hopital au domicile base sur la readaptation lente. Cette etude qualitative descriptive se concentrait sur les lacunes de services, ainsi que sur les obstacles et les facteurs de facilitation lies a la mise en & OELIG;uvre et au fonctionnement du programme. Vingt-trois personnes ont participe a des groupes de discussion ou des entrevues individuelles semi-structurees. Six chercheurs ont analyse les transcriptions de ces entrevues selon une methode thematique inductive. Les themes emergents de cette analyse ont ete classes selon l'echelle socio-ecologique suivante: 1) niveau macro - lacunes de services pendant l'attente du programme, capacite d'accueil limitee du programme et lacunes de services a la suite du programme; 2) niveau meso - manque de connaissance du programme, absence d'un processus precis de recommandation, absence de criteres precis d'admissibilite et necessite d'une meilleure communication entre les milieux de soins; 3) niveau micro - prestation de services, bienfaits du programme pour les participants, communication centree sur la personne, limites structurelles du programme, necessite d'utiliser des parametres de resultats et manque de suivi. La mise en & OELIG;uvre d'un processus fluide de communication et de documentation des renseignements sur les patients et l'utilisation de criteres precis de recommandation et de parametres de resultats normalises pourraient reduire le nombre de recommandations inappropriees et fournir une information utile au personnel qui collabore au programme ou y recommande des patients.