Service coordination: inpatient to outpatient settings for people with complex rehabilitation needs after traumatic injury

Included quantitative studies

Eleven studies (reported in 12 papers) were included in the quantitative section of this review. Nine of these studies were randomised controlled trials (RCTs; Browne 2013, Chong 2013, Hall 2005, Lin 2009, Parson 2019, Ryan 2006, Stenvall 2007, Vikane 2017 and Wiechman 2015), with the remaining 2 being non-randomised cohort studies (Flikweert 2014 and Hall 2018).

One RCT compared the effectiveness of multidisciplinary team care with usual care in general trauma patients, and was conducted in Austrialia (Browne 2013). Another RCT compared the effectiveness of multidisciplinary team care plus structured assessments with multidisciplinary team care only in hip fracture patients, and was conducted in Singapore (Chong 2015). Two RCTs were conducted in Tawainese hip fracture patients: 1 compared the effectiveness of discharge planning by a gerontological nurse with routine discharge planning (Huang 2005) and the other compared comprehensive discharge planning with routine discharge planning (Lin 2009). Another RCT compared supported discharge team care with usual care in general trauma patients, and was conducted in New Zealand (Parsons 2019), while another RCT compared an intensive multidisciplinary intervention with a less intensive intervention in hip fracture patients and was conducted in the UK (Ryan 2006). Please note that this study reported 3-month and 12-month data in 2 separate publications. An RCT compared the effectiveness of multidisciplinary outpatient treatment with usual care by general practitioners in patients with traumatic brain injury (TBI), and was conducted in Norway (Vikane 2009), while another RCT compared the effectiveness of an extended care practitioner care plus telephone calls with standard outpatient care in burn injury patients, and was conducted in the USA (Wiechman 2015).

The final RCT compared the effectiveness of a multidisciplinary post-operative rehabilitation intervention with conventional post-operative rehabilitation, and was conducted in Sweden (Stenvall 2007). This intervention spanned rehabilitation coordination both while patients were in inpatient settings and when patients were transferring between inpatient and outpatient settings. It therefore met the inclusion criteria for 2 of the coordination of rehabilitation reviews. Stenvall (2007) is therefore included in both reviews, with the outpatient outcomes reported in this review and the inpatient outcomes reported in the review focusing on coordination of inpatient rehabilitation services.

One cohort study compared the effectiveness of a multidisciplinary care pathway with standard care in hip fracture patients and was conducted in the Netherlands (Flikweert 2014), while the other cohort study compared the effectiveness of a traumatic clinical care coordination with no traumatic clinical care coordination and was conducted in the USA (Hall 2018).

Included qualitative studies

Nineteen primary studies were included in the qualitative section of this review. One of these studies was conducted in the UK (Odumuyiwa 2019), 7 were conducted in Australia (Barclay 2019, Braaf 2018, Isbel 2017, Kennedy 2012, Kornhaber 2019, O’Callaghan 2012 and Turner 2011), 4 in Canada (Glenny 2013, Jeyaraj 2013, Sims-Gould 2012 and Singh 2018) and 3 in Denmark (Christensen 2018, Graff 2018 and Lindahl 2013). One study each was carried out in Belgium (Christiaens 2015), Portugal (Sena Martins 2017) and Norway (Slomic 2017). The final study was a multinational study between France and Finland (Jourdan 2019).

One paper was a framework-based meta-synthesis of 12 primary studies, all conducted by the same research team in Canada (Stolee 2019). It is important to note that this paper included 2 of the above studies in their synthesis (Glenny 2013 and Sims-Gould 2012). In order to prevent double counting of data, findings have only been extracted from Glenny 2013 and Sims-Gould 2012 if they have not appeared in Stolee 2019.

Excluded studies

Studies not included in this review are listed, and reasons for their exclusion are provided in appendix K.

Summary of the quantitative evidence

No meta-analyses were performed as the interventions or outcomes were either not sufficiently similar to allow them to be combined or they were not reported by more than one study.

Of the pre-defined outcomes, evidence was found for:

• Patient satisfaction
• Length of hospital stay
• Return to work or education
• Overall quality of life
• Changes in activities of daily living

No evidence was found for outcomes relating to carer impact or unplanned readmission rates following discharge.

One RCT compared the effectiveness of an MDT care with usual care (Browne 2013). No statistically or clinically important difference was found in length of hospital stay between the groups. Additionally, no statistically or clinically important difference was found between groups in return to work or education, number of participants with impairment of ADL or FIM scores at 6 months post-discharge. All of these effect estimates were judged to be of very low quality.

One RCT compared the effectiveness of an MDT care plus structured assessments with MDT care only (Chong 2015). No statistically or clinically important difference in patient satisfaction at discharge was found between the groups. The evidence was judged to be of very low quality. Median length of hospital stay was reported in the study and, based on statistical analyses by the authors, was found to be statistically importantly lower in the MDT plus structured assessment than the MDT only group. However, the authors did not report whether this difference was clinically important and the evidence was judged to be of very low quality. No statistically or clinically important differences in overall quality of life (measured using SF-12 physical component score and SF-12 mental component score) or changes in ADL (measured using modified Barthel Index and Montebello Rehabiliation Factor score) were found at either 6 or 12 months. Evidence ranged from very low to low quality for these outcomes.

One cohort study compared the effectiveness of multidisciplinary care pathway with standard care (Flikweert 2014). According to the statistical analyses performed by the author, the median hospital length of stay was statistically importantly shorter in the multidisciplinary care pathway group. However, the authors did not report whether this difference was clinically important. This was judged to be of moderate quality.

One cohort study compared the effectiveness of traumatic clinical care coordination with no traumatic clinical care coordination (Hall 2018). Length of hospital stay was both clinically and statistically importantly longer in the traumatic clinical care coordination group when compared to the control group. This evidence was judged to be of low quality.

One RCT compared the effectiveness of discharge planning by a gerontological nurse with routine discharge planning (Huang 2005). The length of hospital stay was statistically and clinically importantly shorter in the discharge planning by a gerontological nurse group. Overall quality of life (measured using SF-36) and changes in ADL (measured using the Bathel Index) were statistically and clinically importantly higher (better) at discharge, at 2 weeks post-discharge and at 3 months post-discharge in the discharge planning by a gerontological nurse group when compared to the routine discharge planning group. Evidence ranged from low to moderate quality.

One RCT compared comprehensive discharge planning with routine discharge planning (Lin 2009). Outcomes were reported for patient satisfaction, length of hospital stay and changes in ADL (measured using Functional Status Subscale) up to 3 months post-discharge. No statistically or clinically important differences were reported between the groups for any of these outcomes. Evidence was judged to be very low to low quality.

One RCT compared supported discharge team with usual care (Parsons 2019). Length of hospital stay was statistically signficantly shorter in the supported discharge group compared to the usual care group. As the authors did not report standard deviations, and there are no published MIDs, clinical significance could not be determined. Evidence was of moderate quality.

One RCT compared an more intensive MDT care intervention with a less intensive MDT care intervention (Ryan 2006). Outcomes were reported for overall quality of life (measured using EQ-5D and EQ-VAS) and changes in ADL (measured using Barthel Index and Franchay Activities Index) at 3 and 12 months. No statistically or clinically important difference was found between the groups at either time point, and evidence was all judged to be very low quality.

One RCT compared the effectiveness of a multidisciplinary post-operative rehabilitation intervention with conventional post-operative rehabilitation (Stenvall 2007). No statistically or clinically important differences were found between the groups in the proportion of participants achieving independence in P-ADL at the 4 or 12 months post-operative follow-up or in each of the Katz ADL grades at discharge. Additionally, there were no statistically or clinically important differences in the proportion of participants achieving each Katz ADL score at 12 months, apart from grade G, where a statistically and clinically importantly lower number of participants achieved Grade G in the multidisciplinary post-operative rehabilitation compared to conventional post-operative rehabilitation. There was a statisticcally and clinically important increase in the proportion of participants returning to at least the same Katz ADL levels as before trauma in the multidisciplinary post-operative rehabilitation group compared to the conventional post-operative rehabilitation group at 12 months (although this was not true at 4 months follow-up). The evidence was judged to be of very low quality for all outcomes.

One RCT compared the effectiveness of multidisciplinary outpatient treatment with usual care by general practitioners (Vikane 2009). There was no statistically or clinically important differences between the groups in the proportion of participants able to return to work or changes in ADL (measured using the Glasgow Outcome Scale) at 12 months post-injury. Evidence was judged to be of very low quality.

One RCT compared the effectiveness of an extended care practitioner care plus telephone calls with standard outpatient care (Wiechman 2015). No statistically or clinically important differences were found between groups in patient satisfaction, overall quality of life (measured using the mental component of SF-12) or changes in ADL (measured using Goal Attainment Score) at either 6 or 12 months. There was a statistically, but not clinically, importantly higher (better) SF-12 physical component score in the extended care practitioner care plus telephone calls group at 6 months. However, this had disappeared at 12 months when no statistical or clinical important difference in SF-12 physical component score was reported. Evidence was very low to low quality for outcomes.

Summary of qualitative evidence

The views of adults with complex rehabilitation needs after traumatic injury, as well as staff who work in rehabilitation services and/or social services, were thematically analysed to find what they believed to be important for coordinating and delivering rehabilitation services and social services across transfer from inpatient to outpatient rehabilitation services. ‘Coordination’ was considered to relate mostly to the ways services organise within themselves, and ‘delivery’ was considered to relate mostly to how these should operate in front-line contact with service users. Six overarching themes were identified that had a total of 26 sub-themes (see appendix F).

The theme ‘service commissioning’ related to service coordination, as did the theme ‘integrating multiple services’ although some parts also crossed into delivery. The themes ‘delivery’, ‘individual needs’, and ‘information’ were all a part of how services should be delivered, and these were intersected by the theme of ‘timing’ and the need for action and consideration before, during and after discharge to the community. Although all the sub-themes are relevant to the question, some relate very practically and conceptually to others and this is indicated by blue arrows.

Summary of relevant qualitative and quantitative evidence

This is a mixed methods review, using parallel synthesis. Quantitative and qualitative data were analysed and synthesised separately and integrated through the committee’s interpretation of results, described in the committee’s discussion of the evidence.

Some of the qualitative evidence helped to explain or contextualise the quantitative findings and Table 6 shows where this was the case. Table 6 lists the sub themes from the qualitative evidence and matches it with the quantitative evidence from interventions targeting the identified area of coordination. It should be noted that not all aspects of a quantitative intervention will relate to a qualitative theme. Interventions often include features of more than 1 theme, and can therefore appear multiple times.

The contents of Table 6 are restricted to the results of the quantitative evidence and the qualitative themes this evidence speaks to. The following themes did not appear in any of the identified quantitative studies: 1.2 Community services and facilities; 1.4 Rural services; 2.2 Inter-service awareness and relationships; 3.1 Continuity of staff; 3.2 Include family; 3.5 Delivery at home; 3.6 Technology; 4.2 Prognosis; 5.2 Admission criteria; 5.3 Specialists; 6.1 Gradual; and 6.3 Gap in service. Additionally, 2 of the quantitative interventions did not include any of the qualitative themes identified in this review. Chong 2013 compared MDT care plus structured assessments and checklists with MDT care only and Ryan 2006a compared more intensive MDT care with less intensive MDT care.

For details of all study results, see the adult Summary of the quantitative evidence and Summary of qualitative evidence sections above.

Included quantitative studies

One study was included in this review, a RCT conducted in Brazil which compared a family-supported rehabilitation programme to a clinician-delivered rehabilitation programme in children with TBI (Braga 2005).

Included qualitative studies

One study was included for this review, a qualitative study conducted in healthcare professionals involved in acquired brain injury (ABI) rehabilitation in Canada (Rashid 2018).

Excluded studies

Studies not included in this review are listed, and reasons for their exclusion are provided in appendix K.

Summary of the quantitative evidence

No meta-analyses were performed as the interventions or outcomes were either not sufficiently similar to allow them to be combined or they were not reported by more than one study.

Of the pre-defined outcomes, evidence was only found for changes in activity of ADL. No evidence was found for:

• Patient satisfaction
• Length of hospital stays
• Return to nursey, education, training or work
• Overall quality of life including sleep
• Carer impact
• Unplanned readmission

One RCT found that a family-supported rehabilitation programme was associated with a statistically significantly, but not clinically importantly, higher (better) motor development score (as measured by the SARAH scale of motor development) compared to a clinician-delivered rehabilitation programme in children with TBI (Braga 2005).

Summary of the qualitative evidence

The following sub-groups were specified in the protocol but no evidence was found.

• Major trauma/non-major trauma
• Children and young people who are currently receiving social care services/not receiving social care services
• Children on at risk register/not on the register
• Children from lower socioeconomic group/not from lower socioeconomic groups

Additionally, no evidence was found for the coordination of rehabilitation services and social services.

Please see Table 9 for a summary of the extracted themes.

Summary of relevant qualitative and quantitative evidence

The quantitative and qualitative results were extracted, analysed and summarised separately before being considered together in an overall synthesis of the evidence. Table 10 lists the sub-themes identified in the qualitative evidence that are also addressed by the identified quantitative evidence along with the results of the corresponding quantitative evidence. It should be noted that not all aspects of a quantitative intervention will relate to a qualitative theme. Interventions often include features of more than 1 theme, and will therefore appear multiple times.

The contents of Table 10 are restricted to the results of the quantitative evidence and the qualitative themes this evidence speaks to. The following themes did not appear in the identified quantitative study: 1.1 Setting common goals and 2.2 Importance of community support. Peer support was a theme identified in the qualitative literature, and was a component of the family-supported rehabilitation intervention. However, this feature was also offered to the clinician-delivered rehabilitation control group and did not differ between groups. Due to this, it has not been included in the above synthesis.

For details of all study results, see the children and young people Summary of the quantitative evidence and Summary of qualitative evidence sections above.

Included studies

A systematic review of the economic literature was conducted but no economic studies were identified which were applicable to these review questions.

See the literature search strategy in appendix B and study selection flow chart in appendix G.

Excluded studies

Economic studies not included in these reviews are listed, and reasons for their exclusion are provided in appendix K.

The outcomes that matter most

The quality of the evidence

Benefits and harms

High quality qualitative evidence from the theme ‘Prognosis’ in the adult review showed that people with rehabilitation needs want information about their condition, probable long-term prognosis and how this could affect their lives in future. The committee agreed with this finding, but added that this can often be difficult to correctly predict and that not everyone with traumatic injuries will want this information. Therefore, they added that prognoses should only be delivered after receiving the views and opinions of the entire MDT so that any considerations and limitations can be conveyed to patients. Additionally, healthcare staff might be delivering sensitive and distressing information which should be communicated in a private and thoughtful manner.

Moderate quality qualitative evidence from the theme ‘Inter-service communication of information’ in the adult review showed that people with rehabilitation needs and healthcare staff believe that relevant healthcare information should be communicated in a timely and simple manner. Particularly, a relevant history of the patient’s events, injuries, treatments, and results (for example, x-rays) should be passed on to services in advance. This theme included evidence from a variety of traumatic injury populations, as well as moderate quality quantitative evidence from 2 quantitative studies reporting a significantly shorter length of hospital stay during interventions that included prompt information exchange prior to discharge. The committee discussed that one way of facilitating this simple transfer was to make sure that all the relevant information was collated into a rehabilitation plan, so it is all in one place when needed. The committee agreed that data linkage is a very important factor across the rehabilitation healthcare pathway. Not only does this greatly assist co-ordination within and between rehabilitation settings, but provides reliable data for audits, service reviews and pathway improvements. The committee therefore recommended services use a unique identifier when communicating rehabilitation information between settings. Ideally, this should be their NHS number as this can be used by a wider number of services and settings within the NHS (rather than just rehabilitation). The use of a rehabilitation plan will also help to increase consistency between members of the rehabilitation MDT. Moderate quality qualitative evidence from the theme ‘Interdisciplinary consistency’ in the adult review showed that people undergoing rehabilitation are confused when they receive different information and instructions from different healthcare professionals. This in turn decreases their trust in rehabilitation services which may cause decreased engagement in their rehabilitation programme. The committee recommended that the rehabilitation plan includes input from the whole MDT in order to increase consistency. Very low quality qualitative evidence from the theme ‘Format’ in the adult review reports that people with rehabilitation needs may find information easier to understand and retain if it is presented to them in plain, accessible language. The committee agreed if information is not written in an accessible format, it can lead to confusion, and therefore specified that the rehabilitation plan should be written in clear and easy-to-understand language.

The benefits of a shared rehabilitation plan between healthcare professionals and people undergoing rehabilitation after traumatic injury was supported by high quality qualitative evidence from the theme ‘Inform about services and plans’ in the adult review. This finding showed that people with rehabilitation needs after traumatic injury appreciate being offered information about rehabilitation, believing that it smoothes transitions between healthcare settings (particularly when being discharged into the community). This information should include information on what services are available to them, how to access them, what arrangements have been made by healthcare professionals and what they may need to arrange themselves. Educating people on these matters empowers them and increases engagement in rehabilitation. Three of the included quantitative studies investigated the effectiveness of using a central healthcare professional for people to contact, and to help co-ordinate rehabilitation. The committee discussed the conflicting quantitative evidence identified in the adult population. One study investigating a discharge planning intervention versus routine care reported evidence of a clinically importantly shorter hospital length of stay (low quality evidence), as well as clinically importantly higher quality of life (moderate quality evidence) and changes in activities of daily living up to 3 months post discharge (moderate quality evidence) in the group that received the discharge planning intervention. This was contradicted by results from another study using a trauma clinical care co-ordinator, which found a clinically importantly longer length of hospital stay in the group who received input from a trauma clinical care co-ordinator. However, this intervention intentionally increased the length of stay in people receiving the intervention and the committee therefore disregarded the evidence. The remaining study compared an extended care practitioner plus telephone calls intervention to standard outpatient care. This study reported no clinically important difference between groups in patient satisfaction, overall quality of life or changes in activities of daily living. Despite the conflicting evidence, the committee agreed that their experience and expertise support the beneficial effects of informing people about their rehabilitation plans, and noted that the qualitative evidence also encompassed a variety of different trauma populations (general trauma, burns, hip fracture and brain injury), so was widely applicable. They noted that they have made several recommendations throughout the guideline regarding keeping people educated and informed of their rehabilitation options and support available. They used the above evidence to expand and strengthen recommendations on what the rehabilitation plan should include, which healthcare professionals it should be shared with, and how it should be shared with people undergoing rehabilitation.

Low quality evidence from the theme ‘Personalisation’ in the adult review showed that both healthcare staff and people with rehabilitation needs after traumatic injury feel that a rehabilitation plan should be tailored to each person (for example, their age, co-morbidities, physical function), and should be flexible around other commitments. It will also need to take into consideration particular vulnerabilities (for example, housing or risk of substance misuse). Seven of the included quantitative studies identified in the adult review stressed the importance of personalising the rehabilitation pathway for patients, rather than a standard ‘one-size-fits-all’ approach. Of the 5 that reported length of hospital stay, 3 reported a clinically significantly shorter stay in hospital for people receiving personalised rehabilitation care when compared to the standard rehabilitation care (judged to be moderate to low quality). Furthermore, 1 study investigating the effectiveness of a discharge planning intervention reported that is was associated with a clinically importantly higher quality of life (moderate quality) and changes in activities of daily living up to 3 months post discharge (moderate quality) compared to standard care. No clinically important difference was found for either patient satisfaction or return to work or education (very low quality, reported in 1 study each). The committee recommended including people in developing their rehabilitation plan, to ensure that it is personalised and focused on the most important goals to the person. The committee also applied this evidence to agree the importance of personalisation at all stages of the rehabilitation pathway, reporting that it promoted communication, as well as increasing trust and engagement with rehabilitation services. The committee used this evidence to strengthen several recommendations throughout the guideline that highlight the importance of a holistic and individualised rehabilitation programme.

High quality evidence from the theme ‘Advocacy’ in the adult review showed that adults with rehabilitative needs reported that they sometimes relied upon family members to research available rehabilitation services, support them with arranging appointments and completing administration, and starting conversations with healthcare professionals. However, advocacy services were not supported by the quantitative evidence (also in the adult population), with no difference reported for patient satisfaction, overall quality of life or changes in activities of daily living between groups receiving extra coordination of rehabilitation services when compared to those who did not. One study reported a higher length of hospital stay in people receiving advocacy as part of their intervention. However, the committee discussed that the intervention in question had specifically increased hospital stay in order to complete all aspects of the intervention, and decided to disregard this low quality evidence. The committee decided not to make recommendations in the area of advocacy, but did discuss the strength of the qualitative evidence and the positive testimonies of support received from healthcare professionals shared by the lay members. Therefore, the committee highlighted the legal entitlement of certain populations of people to professional advocacy services under the Mental Capacity Act 2005 and/or the Care Act 2014. Further information can also be found in the NICE guideline on decision making and mental capacity which can be used as a guide to ensure that people are supported to make decisions for themselves when they have the mental capacity to do so or, where they lack the mental capacity to make specific decisions, they remain at the centre of the decision-making process.

High quality qualitative evidence from the theme ‘Continuity of staff’ in the adult review showed that people with rehabilitation needs prefer to see the same healthcare professionals wherever possible. This is because patients and healthcare staff both invest time to build trust and rapport with each other, which can lead to more honest and open communication. When healthcare staff are changed, service users lose that relationship and can become discouraged with continuing rehabilitation. Additionally, there is an increased resource impact of time taken to re-share history and personal details, as well as the possibility of mistakes when information is not passed on. Both the healthcare professionals and lay members of the committee agreed with this theme. While it was acknowledged that full continuity is not always possible, the committee highlighted the importance of considering this aspect of a patient’s rehabilitation journey. The committee discussed periods of transfer when changes in rehabilitation teams are unavoidable (for example, when being discharged back into the community), and how this can be managed. In their experience, community teams meeting patients and families before the transfer of care, rather than a ‘cold’ transfer, is very important in making people feel more comfortable with the change. It allows introductions in a less formal setting, a detailed handover of care needs from the current clinical team, and time for any questions patients and family members might have. The committee were aware that time is often limited during scheduled rehabilitation appointments, and this extra meeting would decrease pressure for all parties in the subsequent appointments.

Low to moderate quality quantitative evidence in the adult review showed that interventions that focused on the early initiation of conversations about discharge led to a decreased length of hospital stay, increased overall quality of life and increased changes in activities of daily living. Moreover, these differences were sustained at 3 months after discharge. These results were supported by low quality qualitative evidence from the theme ‘Start early’ in the adult review, which shows that both healthcare staff and adults with rehabilitation needs believe that discussions about discharge planning should begin early, in order to allow for a gradual incorporation of necessary exercises and adjustments into rehabilitation plans. The committee used their experience and expertise to recommend that these discussions should be multidisciplinary, in order to capture the full range of exercises and adjustments that a person will need once discharged from inpatient services. However, the committee were also aware that not every rehabilitation setting will be adequately resourced to deliver this discharge planning. Similarly, it might not be appropriate to start discharge planning conversations early (for example, if people are still distress or confused, leading to a difficultly processing and retaining information). Therefore, the committee suggested that this format of discharge planning be considered, but not mandatory.

High quality qualitative evidence from the theme ‘Include family’ in the adult review reported that healthcare staff and adults with rehabilitation needs are aware of the significant support family members can offer, especially when discharged into the community. This was somewhat supported by quantitative evidence from the children and young people’s population, where a family supported rehabilitation programme reported significantly (but not clinically) importantly improved activities of daily living when compared to a clinician-delivered rehabilitation programme. The committee discussed that this support is often invaluable, covering potential gaps in services and coordination of care during the transition process. Therefore, they recommended that family members be actively involved in the discharge planning process as well receiving any rehabilitation education they may need. However, they also are aware of a potential safeguarding aspect of a blanket recommendation to include family members in discharge planning (for example, if there are disagreements about what rehabilitation options should be taken). They therefore highlighted that this inclusion should only be done after consent has been given by patients and if families feel comfortable with it.

High quality qualitative evidence from the theme ‘Gradual’ in the adult review reported that healthcare staff and adults with rehabilitation needs believe that rehabilitation should include a gradual and incremental return to the community. The committee discussed that this softer discharge approach can reduce the distress of the sudden loss of inpatient-support. In their experience, using local step-down wards, pre-discharge weekend home visits and supported community accommodations are all good ways of providing a continued level of support for rehabilitation patients. However, the committee agreed that this strategy is not always needed by patients, and may even at times prolong time away from home which brings its own disadvantages. Additionally, there is a corresponding increase in the level of planning healthcare professionals will need to undertake in order to organise these interventions. Therefore, the committee recommended that this approach is offered to rehabilitation patients with significant ongoing medical and therapy needs, where their experience suggests the most benefit will be had.

High quality qualitative evidence from the theme ‘Integrated multidisciplinary team approach’ in the adult review showed that healthcare professionals and people undergoing rehabilitation highlight the importance of a multidisciplinary team approach when delivering rehabilitation after traumatic injury. This is especially true when transferring from inpatient to outpatient care, to co-ordinate medical and social support needs. A multidisciplinary team was involved in 5 of the included quantitative studies identified in the adult review. Three of these studies reported length of hospital stay as an outcome measure, with 2 reporting moderate quality evidence showing a clinically importantly shorter length of stay in the groups that received multidisciplinary discharge coordination Three studies also reported changes in activities of daily living, all of which were very low quality. Of the 14 measures of activities of daily living reported, there were 2 clinically importantly better results in intervention groups that received multidisciplinary discharge coordination, with the remaining 12 reporting no clinically important difference between the groups. Very low quality evidence from 2 of these studies showed no clinically important difference between the groups in return to work or education either. The committee discussed how the quantitative results did not agree with their clinical experience. They noted that the included studies varied in the amount of post-discharge support provided by the multi-disciplinary team and the length of the interventions. Because of this and the quality of the quantitative evidence, the committee made their recommendations based on the above high quality evidence from the theme ‘Integrated multidisciplinary team approach’, supplemented by 3 additional themes identified for this review. High quality qualitative evidence from the theme ‘Interservice awareness and relationships’ in the adult review shows that healthcare staff find it helpful to work with other agencies if they have the opportunity to build a working relationship. The opportunity to meet in person may help to delivery better integrated and coordinated rehabilitation care. Moderate quality qualitative evidence from the theme ‘Interdisciplinary consistency’ (in the adult population) and very low quality evidence from the theme ‘Setting common goals’ (in the children and young people population) shows that people find it confusing when different professionals provide them with inconsistent information, advice or instructions. This in turn decreases their trust in rehabilitation services which may decrease their engagement in their rehabilitation programme. Arranging pre-discharge meetings or joint-handover sessions will allow professionals from different settings to directly communicate with each other, increase their opportunity to form working relationships and ensure that the same information is provided to all parties at the same time. Finally, low quality qualitative evidence from the theme ‘Home adjustments’ in the adult review showed that people may need home adjustments in order to increase their independence and aid rehabilitation progress. Arranging a pre-discharge planning meeting with community practitioners will not only increase communication between healthcare and social care professionals, it will also allow any home adjustments to be noted and implemented by the relevant community teams before people are discharged back home. However, the committee were also aware that not every rehabilitation setting will be able deliver this pre-discharge meeting, as finding a time for suitable for multiple agencies presents a challenge. Therefore, the committee suggested that this meeting be considered, but not mandatory.

High quality qualitative evidence from the theme ‘Point of contact’ in the adult review showed that adults appreciated a single point of contact to provide information, support and rehabilitation co-ordination as they transfer from inpatient to outpatient settings. This was supported by high quality qualitative evidence from the theme ‘Case co-ordinator’ (also in the adult review) showing that healthcare professionals and adults with rehabilitation needs appreciated being able to communicate with one source for all information regarding a person’s rehabilitation plan. Additional very low quality evidence from the theme ‘Case workers’ in the children and young people population was consisted with this finding. Three of the included quantitative studies investigated the effectiveness of using a central healthcare professional for people to contact, and to help co-ordinate rehabilitation. The committee discussed the conflicting quantitative evidence identified in the review population. One study investigating a discharge planning intervention versus routine care reported evidence of a clinically importantly shorter hospital length of stay (low quality evidence), as well as clinically importantly higher quality of life (moderate quality evidence) and changes in activities of daily living up to 3 months post discharge (moderate quality evidence). This was contradicted by results from another study using a trauma clinical care co-ordinator, which found that the length of hospital stay was clinically importantly longer in the group who received input from the trauma clinical care co-ordinator. However, this intervention intentionally increased the length of stay in people receiving the input from the trauma clinical care co-ordinator and the committee therefore disregarded the evidence. The remaining study compared an extended care practitioner plus telephone calls intervention with standard outpatient care. This study reported no clinically important difference between groups in patient satisfaction, overall quality of life or changes in activities of daily living. The committee acknowledged the conflicting quantitative evidence, but discussed the strong qualitative evidence presented in this review and in other co-ordination reviews showing that a central point of contact was very helpful in developing relationships with patients and their families. In their experience, this can cause a better rapport with and increased trust in rehabilitation services. The committee discussed concerns about patients assuming that they could contact a named healthcare professional at any time, regardless of shifts and annual leave. However, they agreed that a central point of contact will be particularly important when patients transfer from inpatient to outpatient settings, when care is being handed over to community healthcare teams. This contact can be a team or service within a hospital, which will give support to patients and flexibility in staffing. They recommended that the hospital point of contact be available to patients for a limited period of time after discharge in order to improve continuity of care during this period. The committee gave an example of 3 months which was designed to encompass the transition period while still providing a stimulus to ensure healthcare is properly transferred to the appropriate setting. The committee understood that this recommendation would not necessarily be appropriate for rehabilitation patients with long-term and/or complex conditions that require the cooperation of more than one agency. Here, a continuing relationship between professionals and service users is important to understand personal and medical history as fully as possible, in order to better help patients navigate complicated and interacting agencies. Therefore, the committee recommended that appointing a key worker should be considered for patients with complex or long term conditions and/or social care needs. This can be a healthcare or social care professional, depending on which is more appropriate for the person in question. For children and young people, the healthcare or social care professional should also have experience in education and training support, as this will form a portion of their social needs. The committee highlighted additional guidance on the role of a named worker for young people transitioning to adult services, which can be found in the NICE guideline on transferring from children’s to adults’ services for young people using health or social care services.

Moderate quality quantitative evidence from 1 large study in the adult population investigating a multi-disciplinary care pathway spanning from accident and emergency to eventual discharge from a rehabilitation unit showed a significantly shorter length of hospital stay in patients following the multi-disciplinary care pathway. Clinical importance could not be determined due to only median and IQRs being reported by the study authors, and no MIDs identified either in the literature or from the committee. This was supported by moderate quality evidence from the theme ‘Commission a full service’ in the adult review. This theme described the importance of commissioning and funding rehabilitation pathways covering the entire pathway of a service user, including how services within these pathways should communicate and coordinate. Commissioners should collaborate with other commissioning bodies to ensure that rehabilitation pathways include the full range of services people may need access to (for example, vocational and educational rehabilitation services). The committee discussed that the wider rehabilitation needs of young people who are transferring from paediatric to adult services can be overlooked by commissioners, and therefore specifically mentioned this population. The committee discussed a central aspect of this theme, which described that criteria and rehabilitation milestones should be standardised within the pathway in order to facilitate easy transfer of care. In their experience, without this standardisation and clear direction of how services and healthcare professionals should interact with each other, delays are common from a variety of sources (for example, patients might be able to be discharged from one setting but not fulfil the admission criteria for another, or reduced funding of a downstream service might lead to less capacity and therefore longer waiting lists).

High quality qualitative evidence from the theme ‘Community services and facilities’ in the adult review showed that the availability of community and social services is just as important for overall rehabilitation as rehabilitative medical services are. These services are wide ranging and can include social care, housing, home-adaption, transport services, and sports/recreational facilities. The committee discussed that information on how to access these services should be given to service users prior to discharge, so patients and their families are aware of what is available in their local area.

High quality qualitative evidence from the theme ‘Inter-service awareness and relationships’ in the adult review reported that continuity of care is increased when staff from different areas of the rehabilitation pathway are aware of the other areas (for example, rehabilitation healthcare professionals knowing about social services available in their areas), and have an opportunity to network with these difference areas. The committee discussed how providing networking opportunities will increase staff knowledge of how to access these different facilities, increase the amount of opportunities professionals have to communicate with rehabilitation peers, and strengthen communication channels between organisations.

High quality evidence from the theme ‘Rural services’ in the adult review showed that rural areas are often underserved by specialist rehabilitation services. This is supported by evidence on the availability of specialist services in other co-ordination reviews. The committee discussed that it is not simply rural areas that are underserved, and that there is a wide spectrum of access to specialist rehabilitation professionals across healthcare settings in the UK (for example, some people are unable to leave their homes). This becomes particularly important when people are returning home from a hospital in-patient setting. The committee discussed this finding along with high quality qualitative evidence from the theme ‘Specialists’ in the adult review, which showed that it is important for rehabilitation outcomes that an individual’s ongoing care team include some staff with specialist knowledge, in order to support more generalised healthcare areas. For example, GPs may not have specialist knowledge of a patient’s disabilities and/or conditions following complex trauma but they act as gatekeepers to more specialist services. Therefore, they may not be aware of the appropriate referrals to make when confronted with patients undergoing rehabilitation. The committee discussed that this could be mitigated by ensuring patients have an ongoing rehabilitation team that contains staff with specialist knowledge. The committee were aware that it would not be feasible to recommend increasing the amount of specialist healthcare professionals in this area due to the large resource implications this would have. However, they discussed the feasibility of ensuring that more generalised services received some specialist support to cover rehabilitation populations (for example, psychologist trained in trauma). The committee agreed that, as support would not be needed full time, it could be delivered remotely, which would keep potential resource implications low. However, it would greatly increase the ability of generalised healthcare services to provide rehabilitation care. Low quality evidence from the theme ‘Technology’ in the adult review showed that healthcare professionals and people undergoing rehabilitation after traumatic injury report technology is a useful tool to increase access to rehabilitation specialists. Further low quality qualitative evidence from the theme ‘Delivery at home’ was found regarding the ability of healthcare services to provide rehabilitation at home earlier in the recovery process, which decreases length of length of hospital stay. Both use of technology and options for home rehabilitation have been identified in other co-ordination reviews, and the committee discussed how technology can be used to deliver follow-up, support and rehabilitation sessions to people in the community if these services are not available in their area (for example, videoconferencing being used to deliver specialist rehabilitation sessions at community services or in a person’s home). To support this recommendation, the committee also recommended that professionals in generalised medical settings should have access to individualised peer support and networking opportunities with specialised rehabilitation settings. However, the committee were aware that not every individual has accesss to the technology (for example, the internet) or the level of technological knowledge needed to deliver technology-enabled follow-up, support and rehabilitation sessions. Therefore, they recommended that this is only 1 way that can be considered in increase flexibility and accessability.

Very low quality qualitative evidence from the themes ‘Peer support (in the adult population) and ‘Importance of community support’ (in the children and young people population) showed that healthcare professionals and people undergoing rehabilitation after traumatic injury reported the benefits of support from people with lived experience. Due to the quality of the evidence, the committee used this evidence to strengthen previous recommendations on peer support rather than create new recommednations in this area.

The committee discussed the 3 remaining themes found in the adult population, but decided not to use them to make recommendations. High quality qualitative evidence from the theme ‘Workload and demand’ showed that efficiency can be decreased when staff are overworked and waiting list times may be increased. There was very low quality quantitative evidence supporting this, with changes in activities of daily living being clinically importantly better in participants receiving a multi-disciplinary team post-operative rehabilitation intervention which included increased staffing levels of the wards allocated to this intervention. However, this was only seen in 2 measures of activities of daily living (number of participants achieving independence in activities of daily living at 12 months and number of participants achieving Katz Grade G at 12 months). The other 9 activities of daily living measures did not find a difference between the groups. With this in mind, the large number of settings any recommendations would apply to, and the large resource impact recommendations in this area would have, the committee decided not to use this evidence in any recommendations. Low quality qualitative evidence from the theme ‘Admission criteria’ showed that inflexible admission criteria (for example, income factors or postcodes) can limit the services available to some adults with rehabilitation needs. While the committee discussed the importance of every patient receiving equal treatment access, they have made several other recommendations regarding flexibility of appointments throughout the guideline. While they do not target admission criteria directly, the committee believe that these will lead to greater access for all. Low quality evidence from the theme ‘Gap in service’ showed that, when discharged back into the community, some adults with rehabilitation needs experienced long waiting times before community rehabilitation began. The committee agreed that it was difficult to make specific recommendations to reduce waiting times, but they were confident that the recommendations made from this evidence review (along with co-ordination reviews) will lead to reduced waiting time for rehabilitation services in the longer-term.

Despite the limited evidence identified for children and young people in this review, the committee decided not to make a research recommendation in this area. Within the UK there is a relatively small number of paediatric major trauma centres, making studies in this population difficult. This, combined with the large amount of evidence found for the adult population, meant that the committee decided that other areas of the guideline would benefit more from new research.

Cost effectiveness and resource use

There was no existing economic evidence for this review.

The committee explained that multidisciplinary team reviews happen anyway. If people ask for information about the likely long-term prognosis providing such information only after a multidisciplinary team review will not incur additional resources. In most cases, the long-term prognosis is discussed at multidisciplinary team meetings to plan for long term rehabilitation, i.e. it is not something new that the teams will need to discuss.

The committee discussed delays between acute and rehabilitation settings. The committee explained that trauma systems are efficient and are ready to discharge much quicker than rehabilitation services which by their very nature are of a slower stream with much longer length of stays. The committee discussed potential solutions, e.g. commissioner’s/service managers focus on discharge to the community, making the system work as efficiently as possible, including early discharge conversations and early engagement with social services/funders. The committee explained that the transfer recommendations might make the process more efficient and result in cost savings to services.

Additional professional time might be needed to cover early discharge planning, checking access to community rehabilitation services, and organising home visits. The recommendations imply more coordination between inpatient teams and other health and social care services, which will take more time. However, this additional time spent will result in patients feeling more supported, increasing their confidence in services and improving outcomes. Also, this would only be required for a small number of people with the most complex needs. The committee explained that these recommendations reinforce current practice in this subset of people with the most complex needs for most services. However, there may be resource implications for services that are providing sub-optimal care / are underperforming.

Similarly, the committee explained that if a person has significant ongoing and complex medical and therapy needs, offering a gradual and incremental return into the community, e.g., transfer to a local hospital, a stepdown bed or a pre-discharge visit to a home, is a standard practice. Also, a pre-discharge planning meeting with community practitioners involved in the person’s rehabilitation, social care and support would be a standard practice in people with the most complex needs. These recommendations are not expected to result in a resource impact. However, there may be resource implications for services that are providing sub-optimal care / are underperforming.

The committee explained that for children and young people, meetings between the school or education setting, one or more members of the multidisciplinary team, parents and the child or young person (as appropriate) should be already happening and this recommendation should not represent a change in practice or require additional resources to implement. The committee explained that in spite of the existence of major trauma networks there is still considerable variation in practice around planning, commissioning and coordination of many aspects of rehabilitation. The committee explained that organising services with whole care pathways in mind and collaboration between commissioners represent good practice principles and should be happening across services. Where this is not happening, there may be some resource implications because services will need to set up or extend existing frameworks for more integrated commissioning and collaborative rehabilitation planning. In practice, this may entail more communication, effective information sharing and more meetings between services/practitioners. However, it is also likely to create efficiencies by ensuring that services are joined up and providing integrated care, with a potential to improve access to services, reducing waiting times and improving transfer and discharge practices, and ultimately improve patient outcomes.

The recommendation about giving people and their families and carers information about community rehabilitation and social services and/or national support networks and how they can access these are only about signposting and will not incur additional resources. It might require more practitioner time. However, it is expected to be standard practice for most services.

Most professionals already have networking opportunities. However, the practice may need to change for some services where this is not the case (for example, rural areas). Overall this recommendation is not expected to result in a resource impact for services.

Staff working with complex rehabilitation needs should already have specialist skills, knowledge, expertise, and experience of their particular injuries. This recommendation is stating the principle of good practice and should not result in a resource impact.

The recommendation on making sure that community rehabilitation practitioners have access to training expertise, advice or peer support from specialist services may mean that specialist rehabilitation professionals might need to spend more time providing peer support/training to general services/non-specialists. This could be done in low-cost ways, e.g., virtual meetings, signposting to information sources. The committee noted that if non-specialist healthcare professionals are better supported, people’s needs are more likely to be met locally and there will be less pressure on specialist services. The committee also discussed some benefits of such support to practitioners, e.g., individuals not feeling isolated, sharing experiences, empowerment, which ultimately lead to better care and improved patient outcomes. Overall, the committee expect that basic specialist/support for practitioners might be a cost-saving strategy, e.g. even though clinicians may spend time on initial support, local/community/generalist practitioners will provide care with minimal input from then on. This would also benefit people (e.g. care closer to home, less disruptive) and the health service (e.g. no need to cover travel costs, less reliance on ambulance transport).

The committee discussed recommendation around technology-enabled follow-up and explained that this is already standard practice in some services. The committee also discussed that an individual might have follow-up care/rehabilitation with their initial rehabilitation specialist with, e.g., videoconferencing. The committee member with an experience of trauma discussed that the use of technology might mean that rehabilitation is more accessible, e.g. not driving to appointments. Allows individualised support with the original team. The committee noted that this might result in a higher intervention cost, i.e. support/training local therapist would take half a day to a day versus continuous support by a consultant. However, overall this could be a cost-effective approach, i.e. any cost increase in staff costs could be offset by benefits/cost-savings due to less disruption to care (continuity), no need to train/support local community therapists who may not understand the complexity of a problem, and better patient outcomes.

The committee explained that handover, i.e. between the inpatient multidisciplinary team and community practitioners at the point of discharge, does happen and should not have a resource impact on services. Where this is not happening, more professional time will be required to attend these joint handover meetings. The committee explained that handover is crucial and, if not done appropriately, may adversely affect patient outcomes. For example, a committee member with an experience of trauma referred to a situation where a community therapist advised an individual to undertake weight-bearing, which conflicted with the advice by a specialist rehabilitation therapist. Such a joint handover appointment has the potential to avoid conflicting advice and ensure an individual is receiving appropriate care in the community. This may also reduce the number of people coming back to specialist services with unmet needs, which may require intensive rehabilitation further down the line.

The single patient document, such as a rehabilitation prescription, is standard good practice; however, it is variable. The recommendations on this might have resource implications for services that are providing sub-optimal care / are underperforming.

The committee also discussed a single point of contact (e.g. a clinical nurse specialist) at discharge from the hospital to provide people and their family/carers with information, help and advice. The committee explained that anyone could do this with a clinical background and that it doesn’t have to be one particular person. However, this is currently happening inconsistently, and so this recommendation may represent a change in practice for some services. The committee discussed the benefits of having a single point of contact, including developing relationships with patients and their families, a better rapport with and increased trust in rehabilitation services, particularly when patients transfer from inpatient to outpatient settings, i.e. when care is being handed over to community healthcare teams. Having a single point of contact will provide assurance to individuals and their family/carers, may potentially ensure continuity in care and also engagement with care. The committee was of a view that benefits would offset any additional costs to services where this is not happening, and having a single point of contact for a limited time would represent value for money.

The committee explained that all other recommendations reinforce standard practice and will not require additional resources.

Recommendations supported by this evidence review

This evidence review supports recommendations 1.1.1, 1.2.1, 1.2.2, 1.4.1, 1.4.2, 1.5.7, 1.6.6, 1.7.1, 1.7.6, 1.7.9, 1.7.10, 1.8.1, 1.8.3, 1.8.9, 1.8.15, 1.8.16, 1.8.22 to 1.8.24, 1.9.1, 1.9.2, 1.10.1, 1.10.2, 1.10.6, 1.10.8 to 1.10.10, 1.10.12 and 1.10.14 in the NICE guideline.