Table 4, Summary of included qualitative studies - Service coordination: inpatient to outpatient settings for people with complex rehabilitation needs after traumatic injury

Table 4Summary of included qualitative studies

Study and aim of study	Population	Methods	Themes
Barclay 2019 Aim of study To describe and compare service delivery approaches that aim to support re-integration into the community following SCI in-patient discharge.	N = 10 spinal service centres N=12 healthcare professionals working in SCI rehabilitation Setting: spinal service centres Country (N): Australia: 2 Canada: 2 New Zealand: 1 Norway: 1 Sweden: 1 UK: 1 USA: 2 No further details reported.	Recruitment period: July 2018 – January 2019 Data collection and analysis: Semi-structured interviews Thematic analysis	Integrating multiple services: Inter-disciplinary consistency Delivery: Peer support Delivery: Technology Timing: Gradual Timing: Start early
Braaf 2018 Aim of study To explore major trauma patient’s experiences of communication with healthcare professionals in the initial 3 years post-injury, in hospital, rehabilitation and community settings.	N = 65 adults with major trauma Setting: Victorian State Trauma System Age [mean (SD)]: 50.7 (15.5) years Gender (M/F): 42/23 Length of hospital stay [median (IQR)]: 11 (5.4 - 26.5) days Injury cause (N): Traumatic: 65 Motor vehicle: 22 Fall: 12 Motorcycle: 6 Pedal cyclist: 6 Other: 19	Recruitment period: July 2014 – July 2015 Data collection and analysis: Semi-structured interviews Thematic framework analysis	Integrating multiple services: Inter-service communication of information Integrating multiple services: Case coordinator Integrating multiple services: Inter-disciplinary consistency Delivery: Point of contact Information: Inform about services and plan Information: Prognosis Information: Format Timing: Start early Timing: Gap in service
Christensen 2018 Aim of study To explore the continuity of care between in-patient and outpatient rehabilitation services for Danish veterans with lower-limb amputees.	N = 6 adults with lower-limb amputation Setting: in the community Age [median (range)]: 32 (25-46) years Gender (M/F): 6/0 Time since amputation [median (range)]: 5.7 (2-17) years Injury cause (N): Traumatic: 6 Explosion: 6	Recruitment period: November 2014 – February 2015 Data collection and analysis: Semi-structured interviews and group observations Thematic analysis	Integrating multiple services: Interservice communication of information Delivery: Point of contact Individual factors: Advocacy
Christiaens 2015 Aim of study To explore the rehabilitation and aftercare experiences of severe burn patients and the views of allied healthcare professionals.	N = 57 People with burn injuries (and their parents): 29 Healthcare professionals working in burn rehabilitation: 24 Setting: In the home Characteristics of individuals with burn injuries (and their parents) Burn patients and parents (N): 29 Adult burn patients: 15 Parents of children under 12 years: 8 Parents of adolescents between 12 and 18 years: 3 Adolescents between 12-18 years: 3 Age (N) of adult patients: 18-30 years: 3 31-40 years: 1 41-65 years: 8 > 65 years: 3 Gender: not reported Time since injury: not reported Injury cause: not reported Characteristics of healthcare professionals Profession (N): Care coordinators: 4 Nurses: 4 Physicians: 7 Physiotherapists: 3 Psychologists: 4 Social workers: 2 Experience working in burn rehabilitation: not reported	Recruitment period: January – April 2013 Data collection and analysis: Semi-structured interviews and focus groups Constant comparative analysis	Service commissioning: Commission a full service Integrating multiple services: Interservice communication of information Integrating multiple services: Case coordinator Delivery: Continuity of staff Delivery: Include family Information: Inform about services and plan Information: Prognosis Individual factors: Specialists Timing: Gradual
Glenny 2013 Aim of study To explore the communication experiences of caregivers and healthcare professionals during transitional care of elderly hip fracture patients from inpatient to community rehabilitation.	N = 35 Caregivers of individuals with hip fracture: 9 Healthcare professionals working in hip fracture rehabilitation: 26 Setting: Throughout hip fracture rehabilitation pathway Characteristics of healthcare professionals only Profession (N): General practitioner: 1 Nurse care manager: 8 Occupational therapist: 6 Physiotherapist: 4 Registered practical nurse: 6 Retirement home care manager: 1 Experience working in hip fracture rehabilitation: not reported	Recruitment period: January – December 2010 Data collection and analysis: Semi-structured interviews Content-based thematic analysis	Delivery: Include family Individual factors: Advocacy
Graff 2018 Aim of study To explore the rehabilitation experiences of adults with TBI up to 4 years post injury, including facilitators and barriers.	N = 20 adults with TBI Setting: In the community Age at recruitment [median (range)]: 39 (25-63) years Gender (M/F): 12/8 Time since injury: not reported. Injury cause: not reported.	Recruitment period: December 2014 – May 2015 Data collection and analysis: Semi-structured interviews Hermeneutical phenomenological thematic analysis	Delivery: Point of contact Information: Inform about services and plan Individual factors: Personalisation Individual factors: Admission criteria Individual factors: Advocacy Timing: Gradual
Isbel 2017 Aim of study To explore the experiences and opinions of healthcare professionals regarding how dementia affects rehabilitation care after hip fracture.	N = 12 healthcare professionals working in hip fracture rehabilitation and dementia Setting: range of rehabilitation hospitals (urban and rural). Profession (N): Clinical nurse specialist: 1 Geriatrician: 5 Nurse manager: 2 Ortho-geriatrician: 2 Physiotherapist: 1 Rehabilitation physician: 1 Experience working in hip fracture rehabilitation: not reported.	Recruitment period: Not reported. Data collection and analysis methods: Semi structured interviews Thematic analysis	Integrating multiple services: Integrated multidisciplinary team approach Delivery: Include family Timing: Gap in service
Jeyaraj 2013 Aim of study To explore healthcare professionals views on which rehabilitation factors affect complexity TBI outpatient rehabilitation.	N = 12 healthcare professionals working in TBI rehabilitation Setting: TBI rehabilitation outpatient clinic No demographic information reported.	Recruitment period: Not reported. Data collection and analysis: Semi-structured interviews and focus groups Content-based thematic analysis	Service commissioning: Commission a full service Service commissioning: Community services and facilities Integrating multiple services: Interdisciplinary consistency Delivery: Include family Delivery: Delivery at home Individual factors: Personalisation Individual factors: Specialists Timing: Gap in service
Jourdan 2019 Aim of study To compare TBI care pathways and explore the views of healthcare professionals on TBI care provision in Varsinais-Suomi, Finland and Ile-de-France, France.	N = 10 healthcare professionals working in TBI rehabilitation Finland: 6 France: 4 Setting: across TBI rehabilitation care pathways in Ile-de-France and Varsinais-Suomi. Profession (N): ICU practitioner: 1 Neuro-anaesthetist: 3 Neurologist: 4 Neurosurgeon: 2 Experience working in TBI rehabilitation (range): 8-25 years	Recruitment period: Not reported. Data collection and analysis methods: Semi-structured interviews Thematic analysis	Service commissioning: Community services and facilities Service commissioning: Rural services Timing: Gap in service
Kennedy 2012 Aim of study To explore the views of healthcare professionals on the design, implementation and acceptability of a new comprehensive rehabilitation case management (CRCM) model.	N = 32 healthcare professionals working in TBI rehabilitation Setting: Specialised TBI rehabilitation unit Profession (N): Brain injury unit clinicians: 22 External stakeholders: 3 Rehabilitation case manager: 7 Experience working in TBI rehabilitation: not reported	Recruitment period: May 2011 – September 2012 Data collection and analysis: Semi-structured interviews Thematic analysis	Service commissioning: Workload and demand Integrating multiple services: Case coordinator Delivery: Continuity of staff Delivery: Point of contact Timing: Start early
Kornhaber 2019 Aim of study To explore healthcare professional’s experiences of acute care and rehabilitation in patients with burn injuries.	N = 22 healthcare professionals working in burn rehabilitation Setting: range of burn rehabilitation settings (acute, rehabilitation and community). Profession (N): Doctor: 4 Nurse: 9 Occupational therapist: 3 Physiotherapist: 4 Psychologist: 1 Social worker: 1 Experience working in burn rehabilitation: not reported	Recruitment period: 2016 Data collection and analysis methods: Semi-structured interviews Thematic analysis	Service commissioning: Commission a full service Service commissioning: Community services and facilities Service commissioning: Rural services Integrating multiple services: Integrated multidisciplinary team approach Delivery: Include family Delivery: Delivery at home Delivery: Technology Information: Inform about services and plan Individual factors: Personalisation Individual factors: Specialists Timing: Gradual Timing: Start early
Lindahl 2013 Aim of study To explore the experiences of orthopaedic trauma patients when transferring between acute hospital care and community settings.	N = 7 adults with orthopaedic trauma Age [median (range)]: 51 (32-60) years Gender (M/F): 5/2 Time since injury (range): 2-24 months Injury cause: not reported	Recruitment period: January – March 2009 Data collection and analysis: Semi-structured interviews Grounded theory	Service commissioning: Commission a full service Integrating multiple services: Inter-service awareness and relationships Integrating multiple services: Inter-service communication of information Delivery: Continuity of staff Individual factors: Personalisation Individual factors: Home adjustments Timing: Gap in service Timing: Gradual
O’Callaghan 2012 Aim of study To explore the concept of engagement throughout the TBI rehabilitation care continuum and the factors that affect engagement.	N = 23 Adults with TBI: 14 Significant others: 9 Setting: In the community Characteristics of adults with TBI only Age (N): 18-25 years: 2 26-35 years: 3 36-45 years: 3 46-55 years: 3 56-65 years: 3 Gender (M/F): 8/6 Time since injury: not reported Injury cause: not reported	Recruitment period: Not reported. Data collection and analysis: Open interviews Thematic analysis	Service commissioning: Rural services Information: Inform about services and plan Indidivual factors: Specialists Timing: Gradual Timing: Start early
Odumuyiwa 2019 Aim of study To identify the long-term rehabilitation needs of patients with acquired brain injury and their families, and explore their experiences with accessing community services.	Setting: Community ABI rehabilitation services. Stage 1 N = 76 Adults with ABI: 19 Family members: 26 Healthcare professionals working in ABI rehabilitation: 32 Characteristics of adults with ABI Age [mean (range)]: 44.6 (29-72) years Gender (M/F): 10/9 Combined characteristics of adults with ABI and family members Injury cause (N): Traumatic: 34 Non-traumatic: 11 Time since injury (range): 1-41 years Characteristics of healthcare professionals Profession: not reported Experience working in rehabilitation: not reported Stage 2 N = 21 Adults with ABI: 12 Family members: 5 Healthcare professionals working in ABI rehabilitation: 4 Characteristics of adults with ABI Age [mean (range)]: 45 (36-72) years Gender (M/F): 10/2 Time since injury: not reported Injury cause: not reported Characteristics of healthcare professionals Profession: not reported Experience working in rehabilitation: not reported	Recruitment period: Not reported. Data collection and analysis methods: Free text questionnaires and semi-structured interviews Inductive and deductive thematic analysis	Service commissioning: Community services and facilities Service commissioning: Rural services Service commissioning: Workload and demand Integrating multiple services: Integrated multidisciplinary team approach Delivery: Include family Information: Prognosis Individual factors: Specialists
Sena Martins 2017 Aim of study To explore the experiences and views of patients undergoing SCI rehabilitation in Portugal.	N = 93 People with SCI in initial rehabilitation: 28 Healthcare professionals working in SCI rehabilitation: 22 People with SCI in the community: 29 Family and institutional support organisations: 14 Setting: Multiple rehabilitation centres and in the community No demographic information reported.	Recruitment period: Not reported. Data collection and analysis methods: Fieldwork and semi-structured interviews Content analysis	Service commissioning: Community services and facilities Integrating multiple services: Integrated multidisciplinary team approach Delivery: Include family Individual factors: Personalisation
Sims-Gould 2012 Aim of study To explore the views of healthcare professionals on which factors are needed for a successful transition of care in patients after hip fracture.	N = 17 healthcare professionals working in hip fracture rehabilitation Setting: Multiple healthcare settings (community, hospitals and rehabilitation centres) Profession (N): Nursing: 3 Occupational therapy: 4 Physiotherapy: 4 Physician: 2 Social work: 4 Experience in current profession (range): 8 months - 36 years	Recruitment period: March – July 2010 Data collection and analysis: Semi-structured interviews Thematic analysis	Timing: Gradual
Singh 2018 Aim of study To explore the acceptability of a novel mobile phone application designed to facilitate self-management skills in adults with SCI, and their experiences using the application in both inpatient to outpatient settings.	N = 20 adults with SCI Setting: SCI inpatient rehabilitation centre Age [mean (SD)]: 41 (18) years Gender (M/F): 17/3 Time since injury: not reported Injury cause (N): Traumatic: 15 Non-traumatic: 5	Recruitment period: Spring 2015 – Winter 2016 Data collection and analysis: Post discharge exit questionnaire and interactions with patients Thematic analysis	Delivery: Technology
Slomic 2017 Aim of study To explore the experiences of rehabilitation healthcare professionals while transferring TBI and general major trauma patients between specialised and local rehabilitation services.	N = 85 healthcare professionals working in TBI rehabilitation Focus groups: 34 Observations of professional meetings: 41 Semi-structured interviews: 10 Setting: 2 specialised TBI rehabilitation units NB. No demographic information reported for observations of professional meetings. Profession (N): Auxiliary nurse: 2 Cultural educator: 1 Doctor: 1 Nurse: 13 Occupational therapist: 11 Physical therapist: 10 Psychologist: 3 Social educator: 2 Social worker: 4 Speech therapist: 1 Team coordinator: 2 Experience in TBI rehabilitation: not reported	Recruitment period: April 2014 – March 2016 Data collection and analysis: Observations of inter-professional meetings, focus groups and semi-structured interviews Grounded theory	Service commissioning: Community services and facilities Timing: Gradual Integrating multiple services: Integrated multidisciplinary team approach Integrating multiple services: Inter-service awareness and relationships Inter-service communication of information
Stolee 2019 Aim of study To identify factors to improve healthcare transitions in elderly adults with hip fracture and future healthcare transition interventions.	N = 134 Adults with hip fracture: 23 Carers: 19 Healthcare professionals working in hip fracture rehabilitation: 92 Setting: Range of rehabilitation settings (acute, sub-acute, inpatient rehabilitation, outpatient rehabilitation, residential, home) No demographic information reported.	Recruitment period: 2010 Data collection and analysis: Semi-structured interviews Framework-based meta-synthesis	Service commissioning: Commission a full service Service commissioning: Workload and demand Integrating multiple services: Inter-service awareness and relationships Integrating multiple services: Inter-service communication of information Delivery: Include family Information: Inform about services and plan Individual factors: Personalisation Individual factors: Admission criteria
Turner 2011 Aim of study To explore the service and support needs of adults with ABI (and their family carers), and identify factors that night affect these needs, when transitioning between the hospital and home.	N = 38 Adults with ABI: 20 Family carers: 18 Setting: Hospital discharge and in the community Characteristics of adults with ABI only Age [mean (range)]: 40.2 (17-63) years Gender (M/F): 15/5 Length of stay in inpatient rehabilitation (N): <3 months: 12 3–6 months: 7 >6 months: 1 Injury cause (N): Traumatic: 16 Motor vehicle accident: 7 Motor bike accident: 1 Assault: 1 Fall: 4 Other: 3 Non traumatic: 4	Recruitment period: Not reported Data collection and analysis: Semi-structured interviews Grounded theory analysis	Service commissioning: Community services and facilities Service commissioining: Rural services Delivery: Continuity of staff Delivery: Include family Delivery: Point of contact Information: Inform about services and plan Individual factors: Admission criteria Timing: Gap in service

Study and aim of study

Population

Methods

Themes

Barclay 2019

Aim of study

To describe and compare service delivery approaches that aim to support re-integration into the community following SCI in-patient discharge.

N = 10 spinal service centres

N=12 healthcare professionals working in SCI rehabilitation

Setting: spinal service centres

Country (N):

Australia: 2
Canada: 2
New Zealand: 1
Norway: 1
Sweden: 1
UK: 1
USA: 2

No further details reported.

Recruitment period:

July 2018 – January 2019

Data collection and analysis:

Semi-structured interviews
Thematic analysis

Integrating multiple services: Inter-disciplinary consistency
Delivery: Peer support
Delivery: Technology
Timing: Gradual
Timing: Start early

Braaf 2018

Aim of study

To explore major trauma patient’s experiences of communication with healthcare professionals in the initial 3 years post-injury, in hospital, rehabilitation and community settings.

N = 65 adults with major trauma

Setting: Victorian State Trauma System

Age [mean (SD)]: 50.7 (15.5) years

Gender (M/F): 42/23

Length of hospital stay [median (IQR)]: 11 (5.4 - 26.5) days

Injury cause (N):

Traumatic: 65
- Motor vehicle: 22
- Fall: 12
- Motorcycle: 6
- Pedal cyclist: 6
- Other: 19

Recruitment period:

July 2014 – July 2015

Data collection and analysis:

Semi-structured interviews
Thematic framework analysis

Integrating multiple services: Inter-service communication of information
Integrating multiple services: Case coordinator
Integrating multiple services: Inter-disciplinary consistency
Delivery: Point of contact
Information: Inform about services and plan
Information: Prognosis
Information: Format
Timing: Start early
Timing: Gap in service

Christensen 2018

Aim of study

To explore the continuity of care between in-patient and outpatient rehabilitation services for Danish veterans with lower-limb amputees.

N = 6 adults with lower-limb amputation

Setting: in the community

Age [median (range)]: 32 (25-46) years

Gender (M/F): 6/0

Time since amputation [median (range)]: 5.7 (2-17) years

Injury cause (N):

Traumatic: 6
- Explosion: 6

Recruitment period:

November 2014 – February 2015

Data collection and analysis:

Semi-structured interviews and group observations
Thematic analysis

Integrating multiple services: Interservice communication of information
Delivery: Point of contact
Individual factors: Advocacy

Christiaens 2015

Aim of study

To explore the rehabilitation and aftercare experiences of severe burn patients and the views of allied healthcare professionals.

N = 57

People with burn injuries (and their parents): 29
Healthcare professionals working in burn rehabilitation: 24

Setting: In the home

Characteristics of individuals with burn injuries (and their parents)

Burn patients and parents (N): 29

Adult burn patients: 15
Parents of children under 12 years: 8
Parents of adolescents between 12 and 18 years: 3
Adolescents between 12-18 years: 3

Age (N) of adult patients:

18-30 years: 3
31-40 years: 1
41-65 years: 8
> 65 years: 3

Gender: not reported

Time since injury: not reported

Injury cause: not reported

Characteristics of healthcare professionals

Profession (N):

Care coordinators: 4
Nurses: 4
Physicians: 7
Physiotherapists: 3
Psychologists: 4
Social workers: 2

Experience working in burn rehabilitation: not reported

Recruitment period:

January – April 2013

Data collection and analysis:

Semi-structured interviews and focus groups
Constant comparative analysis

Service commissioning: Commission a full service
Integrating multiple services: Interservice communication of information
Integrating multiple services: Case coordinator
Delivery: Continuity of staff
Delivery: Include family
Information: Inform about services and plan
Information: Prognosis
Individual factors: Specialists
Timing: Gradual

Glenny 2013

Aim of study

To explore the communication experiences of caregivers and healthcare professionals during transitional care of elderly hip fracture patients from inpatient to community rehabilitation.

N = 35

Caregivers of individuals with hip fracture: 9
Healthcare professionals working in hip fracture rehabilitation: 26

Setting: Throughout hip fracture rehabilitation pathway

Characteristics of healthcare professionals only

Profession (N):

General practitioner: 1
Nurse care manager: 8
Occupational therapist: 6
Physiotherapist: 4
Registered practical nurse: 6
Retirement home care manager: 1

Experience working in hip fracture rehabilitation: not reported

Recruitment period:

January – December 2010

Data collection and analysis:

Semi-structured interviews
Content-based thematic analysis

Delivery: Include family
Individual factors: Advocacy

Graff 2018

Aim of study

To explore the rehabilitation experiences of adults with TBI up to 4 years post injury, including facilitators and barriers.

N = 20 adults with TBI

Setting: In the community

Age at recruitment [median (range)]: 39 (25-63) years

Gender (M/F): 12/8

Time since injury: not reported.

Injury cause: not reported.

Recruitment period:

December 2014 – May 2015

Data collection and analysis:

Semi-structured interviews
Hermeneutical phenomenological thematic analysis

Delivery: Point of contact
Information: Inform about services and plan
Individual factors: Personalisation
Individual factors: Admission criteria
Individual factors: Advocacy
Timing: Gradual

Isbel 2017

Aim of study

To explore the experiences and opinions of healthcare professionals regarding how dementia affects rehabilitation care after hip fracture.

N = 12 healthcare professionals working in hip fracture rehabilitation and dementia

Setting: range of rehabilitation hospitals (urban and rural).

Profession (N):

Clinical nurse specialist: 1
Geriatrician: 5
Nurse manager: 2
Ortho-geriatrician: 2
Physiotherapist: 1
Rehabilitation physician: 1

Experience working in hip fracture rehabilitation: not reported.

Recruitment period:

Not reported.

Data collection and analysis methods:

Semi structured interviews
Thematic analysis

Integrating multiple services: Integrated multidisciplinary team approach
Delivery: Include family
Timing: Gap in service

Jeyaraj 2013

Aim of study

To explore healthcare professionals views on which rehabilitation factors affect complexity TBI outpatient rehabilitation.

N = 12 healthcare professionals working in TBI rehabilitation

Setting: TBI rehabilitation outpatient clinic

No demographic information reported.

Recruitment period:

Not reported.

Data collection and analysis:

Semi-structured interviews and focus groups
Content-based thematic analysis

Service commissioning: Commission a full service
Service commissioning: Community services and facilities
Integrating multiple services: Interdisciplinary consistency
Delivery: Include family
Delivery: Delivery at home
Individual factors: Personalisation
Individual factors: Specialists
Timing: Gap in service

Jourdan 2019

Aim of study

To compare TBI care pathways and explore the views of healthcare professionals on TBI care provision in Varsinais-Suomi, Finland and Ile-de-France, France.

N = 10 healthcare professionals working in TBI rehabilitation

Finland: 6
France: 4

Setting: across TBI rehabilitation care pathways in Ile-de-France and Varsinais-Suomi.

Profession (N):

ICU practitioner: 1
Neuro-anaesthetist: 3
Neurologist: 4
Neurosurgeon: 2

Experience working in TBI rehabilitation (range): 8-25 years

Recruitment period:

Not reported.

Data collection and analysis methods:

Semi-structured interviews
Thematic analysis

Service commissioning: Community services and facilities
Service commissioning:
Rural services
Timing: Gap in service

Kennedy 2012

Aim of study

To explore the views of healthcare professionals on the design, implementation and acceptability of a new comprehensive rehabilitation case management (CRCM) model.

N = 32 healthcare professionals working in TBI rehabilitation

Setting: Specialised TBI rehabilitation unit

Profession (N):

Brain injury unit clinicians: 22
External stakeholders: 3
Rehabilitation case manager: 7

Experience working in TBI rehabilitation: not reported

Recruitment period:

May 2011 – September 2012

Data collection and analysis:

Semi-structured interviews
Thematic analysis

Service commissioning: Workload and demand
Integrating multiple services: Case coordinator
Delivery: Continuity of staff
Delivery: Point of contact
Timing: Start early

Kornhaber 2019

Aim of study

To explore healthcare professional’s experiences of acute care and rehabilitation in patients with burn injuries.

N = 22 healthcare professionals working in burn rehabilitation

Setting: range of burn rehabilitation settings (acute, rehabilitation and community).

Profession (N):

Doctor: 4
Nurse: 9
Occupational therapist: 3
Physiotherapist: 4
Psychologist: 1
Social worker: 1

Experience working in burn rehabilitation: not reported

Recruitment period:

2016

Data collection and analysis methods:

Semi-structured interviews
Thematic analysis

Service commissioning: Commission a full service
Service commissioning: Community services and facilities
Service commissioning: Rural services
Integrating multiple services: Integrated multidisciplinary team approach
Delivery: Include family
Delivery: Delivery at home
Delivery: Technology
Information: Inform about services and plan
Individual factors: Personalisation
Individual factors: Specialists
Timing: Gradual
Timing: Start early

Lindahl 2013

Aim of study

To explore the experiences of orthopaedic trauma patients when transferring between acute hospital care and community settings.

N = 7 adults with orthopaedic trauma

Age [median (range)]: 51 (32-60) years

Gender (M/F): 5/2

Time since injury (range): 2-24 months

Injury cause: not reported

Recruitment period:

January – March 2009

Data collection and analysis:

Semi-structured interviews
Grounded theory

Service commissioning: Commission a full service
Integrating multiple services: Inter-service awareness and relationships
Integrating multiple services: Inter-service communication of information
Delivery: Continuity of staff
Individual factors: Personalisation
Individual factors: Home adjustments
Timing: Gap in service
Timing: Gradual

O’Callaghan 2012

Aim of study

To explore the concept of engagement throughout the TBI rehabilitation care continuum and the factors that affect engagement.

N = 23

Adults with TBI: 14
Significant others: 9

Setting: In the community

Characteristics of adults with TBI only

Age (N):

18-25 years: 2
26-35 years: 3
36-45 years: 3
46-55 years: 3
56-65 years: 3

Gender (M/F): 8/6

Time since injury: not reported

Injury cause: not reported

Recruitment period:

Not reported.

Data collection and analysis:

Open interviews
Thematic analysis

Service commissioning: Rural services
Information: Inform about services and plan
Indidivual factors: Specialists
Timing: Gradual
Timing: Start early

Odumuyiwa 2019

Aim of study

To identify the long-term rehabilitation needs of patients with acquired brain injury and their families, and explore their experiences with accessing community services.

Setting: Community ABI rehabilitation services.

Stage 1

N = 76

Adults with ABI: 19
Family members: 26
Healthcare professionals working in ABI rehabilitation: 32

Characteristics of adults with ABI

Age [mean (range)]: 44.6 (29-72) years

Gender (M/F): 10/9

Combined characteristics of adults with ABI and family members

Injury cause (N):

Traumatic: 34
Non-traumatic: 11

Time since injury (range): 1-41 years

Characteristics of healthcare professionals

Profession: not reported

Experience working in rehabilitation: not reported

Stage 2

N = 21

Adults with ABI: 12
Family members: 5
Healthcare professionals working in ABI rehabilitation: 4

Characteristics of adults with ABI

Age [mean (range)]: 45 (36-72) years

Gender (M/F): 10/2

Time since injury: not reported

Injury cause: not reported

Characteristics of healthcare professionals

Profession: not reported

Experience working in rehabilitation: not reported

Recruitment period:

Not reported.

Data collection and analysis methods:

Free text questionnaires and semi-structured interviews
Inductive and deductive thematic analysis

Service commissioning: Community services and facilities
Service commissioning: Rural services
Service commissioning: Workload and demand
Integrating multiple services: Integrated multidisciplinary team approach
Delivery: Include family
Information: Prognosis
Individual factors: Specialists

Sena Martins 2017

Aim of study

To explore the experiences and views of patients undergoing SCI rehabilitation in Portugal.

N = 93

People with SCI in initial rehabilitation: 28
Healthcare professionals working in SCI rehabilitation: 22
People with SCI in the community: 29
Family and institutional support organisations: 14

Setting: Multiple rehabilitation centres and in the community

No demographic information reported.

Recruitment period:

Not reported.

Data collection and analysis methods:

Fieldwork and semi-structured interviews
Content analysis

Service commissioning: Community services and facilities
Integrating multiple services: Integrated multidisciplinary team approach
Delivery: Include family
Individual factors: Personalisation

Sims-Gould 2012

Aim of study

To explore the views of healthcare professionals on which factors are needed for a successful transition of care in patients after hip fracture.

N = 17 healthcare professionals working in hip fracture rehabilitation

Setting: Multiple healthcare settings (community, hospitals and rehabilitation centres)

Profession (N):

Nursing: 3
Occupational therapy: 4
Physiotherapy: 4
Physician: 2
Social work: 4

Experience in current profession (range): 8 months - 36 years

Recruitment period:

March – July 2010

Data collection and analysis:

Semi-structured interviews
Thematic analysis

Timing: Gradual

Singh 2018

Aim of study

To explore the acceptability of a novel mobile phone application designed to facilitate self-management skills in adults with SCI, and their experiences using the application in both inpatient to outpatient settings.

N = 20 adults with SCI

Setting: SCI inpatient rehabilitation centre

Age [mean (SD)]: 41 (18) years

Gender (M/F): 17/3

Time since injury: not reported

Injury cause (N):

Traumatic: 15
Non-traumatic: 5

Recruitment period:

Spring 2015 – Winter 2016

Data collection and analysis:

Post discharge exit questionnaire and interactions with patients
Thematic analysis

Delivery: Technology

Slomic 2017

Aim of study

To explore the experiences of rehabilitation healthcare professionals while transferring TBI and general major trauma patients between specialised and local rehabilitation services.

N = 85 healthcare professionals working in TBI rehabilitation

Focus groups: 34
Observations of professional meetings: 41
Semi-structured interviews: 10

Setting: 2 specialised TBI rehabilitation units

NB. No demographic information reported for observations of professional meetings.

Profession (N):

Auxiliary nurse: 2
Cultural educator: 1
Doctor: 1
Nurse: 13
Occupational therapist: 11
Physical therapist: 10
Psychologist: 3
Social educator: 2
Social worker: 4
Speech therapist: 1
Team coordinator: 2

Experience in TBI rehabilitation: not reported

Recruitment period:

April 2014 – March 2016

Data collection and analysis:

Observations of inter-professional meetings, focus groups and semi-structured interviews
Grounded theory

Service commissioning: Community services and facilities
Timing: Gradual
Integrating multiple services: Integrated multidisciplinary team approach
Integrating multiple services: Inter-service awareness and relationships
Inter-service communication of information

Stolee 2019

Aim of study

To identify factors to improve healthcare transitions in elderly adults with hip fracture and future healthcare transition interventions.

N = 134

Adults with hip fracture: 23
Carers: 19
Healthcare professionals working in hip fracture rehabilitation: 92

Setting: Range of rehabilitation settings (acute, sub-acute, inpatient rehabilitation, outpatient rehabilitation, residential, home)

No demographic information reported.

Recruitment period:

2010

Data collection and analysis:

Semi-structured interviews
Framework-based meta-synthesis

Service commissioning: Commission a full service
Service commissioning: Workload and demand
Integrating multiple services: Inter-service awareness and relationships
Integrating multiple services: Inter-service communication of information
Delivery: Include family
Information: Inform about services and plan
Individual factors: Personalisation
Individual factors: Admission criteria

Turner 2011

Aim of study

To explore the service and support needs of adults with ABI (and their family carers), and identify factors that night affect these needs, when transitioning between the hospital and home.

N = 38

Adults with ABI: 20
Family carers: 18

Setting: Hospital discharge and in the community

Characteristics of adults with ABI only

Age [mean (range)]: 40.2 (17-63) years

Gender (M/F): 15/5

Length of stay in inpatient rehabilitation (N):

<3 months: 12
3–6 months: 7
>6 months: 1

Injury cause (N):

Traumatic: 16
- Motor vehicle accident: 7
- Motor bike accident: 1
- Assault: 1
- Fall: 4
- Other: 3
Non traumatic: 4

Recruitment period:

Not reported

Data collection and analysis:

Semi-structured interviews
Grounded theory analysis

Service commissioning: Community services and facilities
Service commissioining: Rural services
Delivery: Continuity of staff
Delivery: Include family
Delivery: Point of contact
Information: Inform about services and plan
Individual factors: Admission criteria
Timing: Gap in service

: ABI: Acquired brain injury; ICU: Intensive care unit; F: Female; M: Male; N: Number; SCI: Spinal cord injury: SD: Standard deviation; TBI: Traumatic brain injury

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

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

Service coordination: inpatient to outpatient settings for people with complex rehabilitation needs after traumatic injury: Rehabilitation after traumatic injury: Evidence review D.2.

NICE Guideline, No. 211.

National Guideline Alliance (UK).

London: National Institute for Health and Care Excellence (NICE); 2022 Jan.

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.