Implementing high intensity home-based rehabilitation for patients following stroke: a mixed methods study.
8 affiliations
- 1Division of Physical Therapy, Department of Orthopaedic Surgery, Duke University School of Medicine, 311 Trent Drive, Durham, NC, 27710, USA. [email protected].
- 2Arts and Medicine Institute, Cleveland Clinic, Cleveland, OH, USA.
- 3Center for Value-Based Care Research, Community Care, Cleveland Clinic, Cleveland, OH, USA.
- 4Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, Ohio, USA.
- 5Center for Connected Care, Cleveland Clinic, Cleveland, OH, USA.
- 6Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.
- 7Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Medical Center, Durham, NC, USA.
- 8Division of Physical Therapy, Department of Orthopaedic Surgery, Duke University School of Medicine, 311 Trent Drive, Durham, NC, 27710, USA.
Abstract
Background
Facility-based rehabilitation following stroke is costly and yields inconsistent outcomes. A high intensity home-based rehabilitation (HIHR) model may improve value and support patient-centered care. Studies are needed to assess contextual factors influencing adoption of HIHR models. The purpose of this study was to examine how clinical adoption of HIHR influenced its reach, maintenance, and fidelity, as well as therapists' perceptions of its acceptability, appropriateness, and feasibility.Methods
HIHR was implemented as a standard-of-care pathway for patients with stroke at one academic hospital and its integrated home health agency. Data were examined for its first two years of implementation guided by the RE-AIM QuEST mixed methods approach. Quantitative data included retrospective clinical data for patients who met HIHR eligibility criteria at hospital discharge (used to measure reach, maintenance, and fidelity) and clinicians' ratings on the Acceptability of Intervention, Intervention Appropriateness, and Feasibility of Intervention Measures. Qualitative data were collected in three focus groups with medical, rehabilitation, and case management clinicians who were potential adopters of HIHR. These qualitative data were analyzed for adoption, fidelity, acceptability, appropriateness, and feasibility. We used a triangulation mixed methods analytic approach, collecting quantitative and qualitative data concurrently, and integrating the data at the interpretation phase.Results
Clinicians rated acceptability, appropriateness, and feasibility of HIHR highly, with mean (SD) scores of 4.35 (0.64), 4.24 (0.56), and 4.00 (0.58), out of 5, respectively. HIHR's reach was 15.0% (49 of 327 eligible patients discharged to HIHR). Maintenance (reach over time) diminished in year 2 compared to year 1 (8.8% vs. 19.4%). Fidelity was poor (only 1 of 49 [2.0%] patients received all HIHR services). Four barriers related to adoption emerged to explain the quantitative findings: clinician education, in-hospital communication, patient eligibility, and service shortfalls.Conclusions
While the HIHR model implemented in one health system was viewed as acceptable, appropriate, and feasible by clinicians, several barriers limited its adoption, undermining reach, maintenance, and fidelity. Key challenges included inconsistent education and in-hospital communication, overly restrictive eligibility criteria, and service delivery gaps. The findings offer valuable insight into how clinical contextual factors influence HIHR adoption, which can inform the model's evolution as it is scaled.
Related
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BibTeX
@article{johnson2026implementing,
title = {{Implementing high intensity home-based rehabilitation for patients following stroke: a mixed methods study.}},
author = {Joshua K Johnson and Lisa M Gallagher and Jordan Alpert and Dolora Wisco and Laura Olitsky and Karen E Steinhauser and Hayden B Bosworth and Amy M Pastva and Michael B Rothberg},
journal = {BMC health services research},
year = {2026},
month = jul,
doi = {10.1186/s12913-026-15176-9},
url = {https://europepmc.org/article/MED/42968151},
note = {CC BY-NC-ND},
}
RIS
TY - JOUR
TI - Implementing high intensity home-based rehabilitation for patients following stroke: a mixed methods study.
AU - Joshua K Johnson
AU - Lisa M Gallagher
AU - Jordan Alpert
AU - Dolora Wisco
AU - Laura Olitsky
AU - Karen E Steinhauser
AU - Hayden B Bosworth
AU - Amy M Pastva
AU - Michael B Rothberg
PY - 2026
DA - 2026/07/30
JO - BMC health services research
DO - 10.1186/s12913-026-15176-9
UR - https://europepmc.org/article/MED/42968151
AB - Background Facility-based rehabilitation following stroke is costly and yields inconsistent outcomes. A high intensity home-based rehabilitation (HIHR) model may improve value and support patient-centered care. Studies are needed to assess contextual factors influencing adoption of HIHR models. The purpose of this study was to examine how clinical adoption of HIHR influenced its reach, maintenance, and fidelity, as well as therapists' perceptions of its acceptability, appropriateness, and feasibility.Methods HIHR was implemented as a standard-of-care pathway for patients with stroke at one academic hospital and its integrated home health agency. Data were examined for its first two years of implementation guided by the RE-AIM QuEST mixed methods approach. Quantitative data included retrospective clinical data for patients who met HIHR eligibility criteria at hospital discharge (used to measure reach, maintenance, and fidelity) and clinicians' ratings on the Acceptability of Intervention, Intervention Appropriateness, and Feasibility of Intervention Measures. Qualitative data were collected in three focus groups with medical, rehabilitation, and case management clinicians who were potential adopters of HIHR. These qualitative data were analyzed for adoption, fidelity, acceptability, appropriateness, and feasibility. We used a triangulation mixed methods analytic approach, collecting quantitative and qualitative data concurrently, and integrating the data at the interpretation phase.Results Clinicians rated acceptability, appropriateness, and feasibility of HIHR highly, with mean (SD) scores of 4.35 (0.64), 4.24 (0.56), and 4.00 (0.58), out of 5, respectively. HIHR's reach was 15.0% (49 of 327 eligible patients discharged to HIHR). Maintenance (reach over time) diminished in year 2 compared to year 1 (8.8% vs. 19.4%). Fidelity was poor (only 1 of 49 [2.0%] patients received all HIHR services). Four barriers related to adoption emerged to explain the quantitative findings: clinician education, in-hospital communication, patient eligibility, and service shortfalls.Conclusions While the HIHR model implemented in one health system was viewed as acceptable, appropriate, and feasible by clinicians, several barriers limited its adoption, undermining reach, maintenance, and fidelity. Key challenges included inconsistent education and in-hospital communication, overly restrictive eligibility criteria, and service delivery gaps. The findings offer valuable insight into how clinical contextual factors influence HIHR adoption, which can inform the model's evolution as it is scaled.
SN - 1472-6963
ER -