Stroke rehabilitation in the Netherlands

In the Netherlands, stroke rehabilitation is organized and delivered in various ways. From the late ‘90, three main types of stroke rehabilitation can be distinguished in the Netherlands.

Firstly, stroke rehabilitation can be offered as institution-based rehabilitation: organized within hospitals, rehabilitation centers and nursing homes. Within institution-based rehabilitation, care is centered around a diagnosis. Professionals are specialized in treating clients with this specific diagnosis. Also, within the institution, regular (formal and informal) inter-professional meetings take place [4].

Secondly, stroke rehabilitation can be offered on outpatient basis. After their transfer home (from the stroke unit or institution-based rehabilitation), stroke survivors can consult outpatient rehabilitation professionals. Stroke survivors receiving outpatient rehabilitation live at home and visit the institution to receive therapy.

Thirdly, stroke rehabilitation can be offered as Home-Based Stroke Rehabilitation (HBSR). During HBSR (Home-Based Stroke Rehabilitation) rehabilitation is offered within the home environment of the client. It includes community-based rehabilitation delivered by primary care professionals, such as occupational therapists, physical therapists, speech therapists, dieticians, social workers, nurses and general practitioners [5]. A broad range of professionals can be involved during HBSR, because the impact of stroke is multifaceted, affecting a broad range of body functions, activities and participation patterns [6]. In the Netherlands primary care is not nationally organized: professionals deliver care from independent private practices and from a variety of institutions. General health insurances cover a certain (predefined) amount of treatment hours for selected disciplines only. The variety in financial legislations between these selected disciplines is large. Sometimes additional treatment hours and/or disciplines are financed, depending on the severity of symptoms, personal circumstances and insurance coverage. Insurance coverage differs per person and depends on the selection of optional insurances.

Home-Based Stroke Rehabilitation (HBSR)

Healthcare professionals and organizations are challenged to provide high quality health and social care, in a client centered and cost-efficient manner. To improve the quality and efficiency of care, the location of care delivery is shifting from institution-based settings to home-based services such as HBSR.

HBSR is known for its positive impact on client outcomes. HBSR resulted in more independent clients [7, 8] who are better at performing daily activities [8, 9] and who are more satisfied with their treatment compared to clients who receive conventional (institution-based) rehabilitation [8–12]. Also, HBSR is shown to reduce the length of hospital stay and to decrease the likelihood of admittance in a long-term stay facility [8]. Furthermore, HBSR has the benefit of treating clients within a familiar environment. According to prior studies this tends to stimulate mental and physical activity, provides more meaning to tasks [13, 14] and prevents potential problems with the transfer of learned skills from the training setting to executing daily activities [15].

Implementing HBSR

In the Netherlands a number of reforms and new policies have been implemented over the last years to facilitate client-centered and cost-effective care. These changes include policies increasing the responsibility of the municipalities for care and welfare on the municipality and transferring more responsibilities from professional carers to civilians and local communities themselves [16]. Despite these efforts, the client-centered and cost-effective provision of high quality care remains a challenge because guidelines, practical suggestions and organisational support seems to be missing [17]. Consequently, both researchers as well as healthcare professionals initiate new regional projects [17–19]. According to the literature, this does not only take place in the Netherlands. Many clients do not receive appropriate care, or receive unnecessary or even harmful care [20].

Major difficulties can arise when implementing innovations, like HBSR, into routine practice. Even though previous studies have shown positive effects of HBSR [7–15], innovations are not always provided to those clients for whom it could be beneficial [21]. Prior studies show that clients and caregivers experience a gap after institution-based rehabilitation (e.g. delays and discontinuity of therapy and feeling abandoned and unsupported) and poor accessibility of community services [22, 23]. In order to further implement an innovation like HBSR, context specific implementation strategies are needed at different levels [24–26].

This Dutch study explores and describes professionals’ perspectives on determinants that could influence the further implementation of HBSR. These insights can guide the selection of context specific implementation strategies. This study will not only provide insight into region specific factors influencing implementation, but also general issues playing a role in the implementation of HBSR.

In this qualitative focus group study we focused on the following questions:

1. How do professionals characterize stroke rehabilitation services that are currently provided in the Netherlands?
2. What are the current and potential barriers and facilitators influencing the implementation of HBSR in their daily practice, according to professionals?

Study design and participants

Two focus groups were conducted in November and December of 2013, utilizing a naturalistic study design [27] based upon a constructionist epistemology for the study’s exploratory aims. Constructionist epistemology have theorized that reality is socially constructed [28, 29]. We wanted to explore professionals’ perspectives on elements that could influence the implementation of HBSR in the future. We anticipated that the interaction between participants during focus groups could maximize the exploration of different perspectives to construct ‘reality’ and would lead to more in-depth insights than individual interviews.

As mentioned in the introduction, a broad range of professionals can be involved in HBSR. In order to include a wide range of perspectives, professionals who were invited to participate were: 1) working in different care environments (primary, outpatient and institution-based care), 2) were experienced in treating clients after stroke, and 3) had different roles (advisor, therapist, specialist and manager) within the rehabilitation process.

Considering the wide range of professional’s perspectives, the presence of a focus group moderator, setting an informal atmosphere and asking to elaborate on statements and/or topics related to the key questions, was considered essential [30]. Individual interviews (using the same interview guide) were considered an alternative when a specific discipline was unable to take part in the focus groups.

According to the guidelines of the local ethical committee of the HAN University of Applied Science, our research was conducted conform the Declaration of Helsinki [31]. Therefore the research project could be conducted without approval of a research ethics committee.

Recruitment and sampling

A convenience sample was used. Contact information of professionals known to the broad national network of two of the authors (ES and BS) were gathered. Professionals were selected if they represented one of the professions that are most frequently involved treating clients after stroke and if they were known to be interested in HBSR. The first author (DV) contacted the professionals by e-mail and informed them about the subject under study and the research questions. Thereafter professionals were asked to participate in a focus group to discuss their point of view with other professionals in relation to the research questions. On request invited professionals were contacted by phone to give additional information about the study. Professionals who were unable to participate in the study were asked to recommend a colleague who might be able to participate (respondent driven sampling). These professionals were thereafter informed and invited by the first author (DV).

Data collection procedure

Data were collected during semi-structured focus groups (or interviews). During the focus groups, efforts were made to set an informal atmosphere. Participants were welcomed with drinks and snacks and names (but not their professional backgrounds) were displayed in front of each participant. After each participant introducing themselves, the focus group moderator (CD) made explicit that different perspectives were expected and welcomed, and that everyone’s viewpoint was highly valued. Data collection started with asking participants to give verbal informed consent to audiotape the interviews.

An interview guide with nondirective, open-ended questions was used [32]. The first questions were aimed at defining HBSR. To get the participants ‘warmed-up’, open-ended questions were directed on gaining insight in the participants’ perceptions and experiences regarding the current status of stroke rehabilitation in the Netherlands. Thereafter the interview guide contained open-ended questions relating to the participants’ opinions about factors influencing the implementation of HBSR within their daily practice. These key questions focused on determinants influencing the implementation of HBSR, as stated in a previous study (i.e. the innovation, the users, the organization and social-political context) [21, 26].

The focus groups were moderated by one of the authors (CD), who has extensive knowledge of HBSR and is experienced in moderating focus group discussions. If necessary, the focus group moderator (CD) asked participants to elaborate on their statements and/or on specific topics related to the key questions (determinants influencing implementation as stated in previous study [21]).

During the focus groups a secretary (DV) was present to take notes. When information was collected on all key questions and no new information emerged, the secretary provided a brief summary of the discussion for verification purposes. Thereafter the focus group moderator asked if anything was missed.

Data analysis

The focus groups and interview recordings were transcribed verbatim by the first author (DV). In the transcript each participant was assigned an ID number, so that statements from participants can be distinguished when reporting results, without using the names of participants.

To identify key issues and patterns in the data, the first author (DV) performed content analyses based on the directed content analysis described by Hsieh & Shannon [32] (using Atlas.ti 7.5.2). Raw data were analyzed through a line-by-line review of the transcripts to identify quotes. Quotes relating to experiences with the current status of stroke rehabilitation in the Netherlands and quotes relating to factors influencing the implementation of HBSR were highlighted. The highlighted quotes were coded through open coding (DV), i.e. no predetermined codes were used [32]. Thereafter, the codes referring to the same key issue were grouped, resulting in categories emerging from the data. These categories were grouped using determinants stated in a previous study [21]: the innovation, the users, the organization and social-political context [21]. This concludes the last stage of the directed content analysis [32]. Consensus on codes and categorization was reached through discussion between two of the authors (DV, ES). After reaching consensus, the final categorization of codes was reviewed by two other authors (CD, PS).

Participants

A total of 15 professionals were willing to participate in the study. Most participants did not know each other, and none of the participants knew the focus group moderator (CD) and the primary researcher (DV). No contact was established with speech therapists working within primary care, despite multiple efforts trying to get in touch by e-mailing potential participants. However, the participating case manager could provide this perspective because she worked as a primary care speech therapist until recently.

The participating professionals were split into two focus groups. Groups were created to reflect a variety in disciplines, gender, age, workplace setting and years of experience [30]. Three professionals could not attend any of the focus groups (a geriatrician, a general practitioner and a rehabilitation physician). These professionals agreed to take part in individual telephone interviews. Unfortunately, the interview with the rehabilitation physician could not be executed within the timeframe of the study due to the tight work schedule of the physician.

Participants were based in the southeastern, southern and western regions of the Netherlands as occupational therapists (n = 2), physical therapists (n = 2), case managers (n = 2), a psychologist, an elderly advisor, a nurse, a speech therapist, a nursing home manager, a manager in allied healthcare, a general practitioner and a geriatrician. The group of participants consisted of five men and nine women between the ages of 28 to 61. Participants’ work settings included hospitals, nursing homes (delivering primary care), home care organizations, a primary care rehabilitation and healthcare center, an outpatient facility and a general practitioners’ office.

Participants’ perspectives on the current status of stroke rehabilitation in the Netherlands

Participants gave their perspectives on how stroke rehabilitation is organized and delivered in the Netherlands, distinguishing 1) institution-based rehabilitation, 2) outpatient rehabilitation and 3) HBSR. According to the participants, the form of rehabilitation that is most suitable for a specific client depends on multiple factors (e.g. clients’ situation, client system and resources). However, it is not clear what the exact clinical criteria (and cut-off points) are.

Firstly, participants stated that intensive inter-professional collaboration characterizes institution-based rehabilitation. According to the participants the regular (formal and informal) inter-professional meetings facilitate inter-professional collaboration. However, participants reported that institution-based rehabilitation is delivered to less people and for shorter durations. The lower (cost) effectiveness compared to other types of rehabilitation were stated as the main reason for this.

Relating to outpatient rehabilitation, participants stated that especially the cognitive outpatient clinic is consulted by a lot of clients after stroke. Participants reported that these clients experience difficulties performing activities of daily living in their own environment after institution-based rehabilitation.

According to participants an important characterization of HBSR is the amount of financed treatment hours. Participants reported that the amount of guidance and treatment they can offer differs, depending mostly on insurance coverage of the client. Participants also stated that HBSR is highly valued as a safety net after discharge. Clients with neurological difficulties can experience paramount problems in their home environment because of (1) the large gap between the institution and the home situation, (2) problems generalizing and transferring learned skills and (3) the rehabilitation setting hindering exposure (and recovery) of cognitive difficulties. It was suggested HBSR could embody client-centered follow-up care after discharge, coordinated by a “key agent”.

Determinants influencing the implementation of HBSR in the Netherlands

Participants reported their perspectives on determinants influencing the further implementation of HBSR, as stated in a previous study (i.e. the innovation, the users, the organization and social-political context) [21]. An overview can be found in S1 Table.