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The experience of Early Supported Discharge (ESD) for stroke survivors
Mrs Lynda Power1, Dr Mary Kennedy-Jones2 & Dr Katherine Harding3
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2 Course Director, School of Occupational Therapy, Swinburne University, 3 Allied Health Research Officer Eastern Health, Arnold Street, Box Hill 1Occupational Therapist ,Yarra Ranges Health, Community Rehabilitation Centre
Early Supported Discharge (ESD) programs are multidisciplinary, specialist stroke teams responsible for planning and co-ordinating smooth discharge from hospital and for providing intensive, goal directed rehabilitation in the community with the aim of
reducing number of hospital bed days required (Fisher et al., 2011) Background
• ESD Programs were initiated in response to the need to accelerate the discharge of stroke patients
admitted to hospital.
• ESD programs have been shown to impact on 3 key areas:
1. Resource Use: ESD programs are a cost effective alternative to conventional treatment,
particularly where services are provided to stroke survivors with mild to moderate disability and
where there is a support network at home (Anderson et.al., 2000; Fisher et.al., 2011).
2. Health Outcomes: ESD programs can reduce long-term dependency and admission to
institutional care as well as reducing the length of hospital stay (Fearon & Langhorn, 2012).
3. Carer Outcomes: The evidence relating to carer burden and participation in ESD is conflicting.
With some studies reporting increased carer burden (Anderson et.al., 2000) while others report no
additional carer burden (Askim,et.al. 2004).
Method
• Qualitative, interpretive paradigm.
• Semi-structured interviews.
• 10 Participants, interviewed within 1 week of
discharge from ESD.
• Interviews audiotaped and transcribed verbatim.
Theme Definition
Theme 1: Home embodies
what I know about me
Being home allowed participants to compare what they knew about themselves pre and post stroke.
Returning to ‘doing’ and previous roles within a familiar context helped them to learn about the
limitations they faced.
Theme 2: Therapists and
peers - the guides to my
recovery
ESD staff provided the expertise for recovery and guidance to improve health outcomes. Participants felt
that home provided therapists with an insight into their individual and unique context for living that
would not have otherwise been understood.
Centre based therapy gave participants exposure to other stroke survivors. It provided opportunity to
observe others progress on a similar journey to them.
Theme 3: The carer is part
of the recovery team
Carers became part of the recovery team, ‘picking up’ when the ESD team finished for the day. Carers
provided physical support with transport and activities of daily living and offered emotional support as
their loved one required it. Participants and their partners reflected on the tiring nature of the intense
program and the need for carers to be prepared for the participants arrival home.
Theme identification
There remains limited information
about the client’s subjective
experience of client participation
in ESD Programs.
Aim: To describe the experience of Early Supported Discharge for stroke survivors attending an ESD Program in Melbourne, Australia.
Eastern Health and ESD
ESD Clients receive :
• 6 day per week service, time limited to 4 weeks;
• Input from a Specialised multidisciplinary team
• A service equal to or greater than that provided by inpatient rehabilitation services
• Support in the transition from acute inpatient care to community rehabilitation.
“I just needed somebody to talk to or things
like that. I think the support was really important. I don’t think you could have done
it without them. That support you get when you’re at home helps keep your mood good
and everything like that.” [Geoff]
Analysis
• Inductive approach used to categorise data.
• Constant comparative method of data analysis.
• Transcripts read and re-read prior to coding.
• 8 sub themes with identification of 3 major themes.
• Data triangulation.
• Member checking (feedback on themes via focus group
and email).
“To get some sense of normality back, you don’t feel like you can move on while you’re in hospital. You have to be out to move on and I wanted to start the process” [Melanie]
Conclusions
• Early access to the home environment highlighted participants limitations post-stroke with previously well-practiced routines and
habits.
• The home environment is unique to each individual. This environment gave therapists and participants the opportunity to gain
insight about interventions that had the power to be therapeutic.
• The experience of ESD was one that included meaningful therapeutic space that allowed exposure to, and opportunities to practice
meaningful roles and routines in a familiar and comfortable environment (home), as well as access to other stroke survivors on a
similar journey (the community centre).
• By sharing their experience with others on a similar journey, participants gained a sense of ‘hope for recovery’, a sense of
‘universality’ and a sense of belonging and acceptance.
• Carers enable participation in the ESD program. Participants expressed concern for the well-being of their carer due to the tiring
nature of the burden of care and felt that carers were ill prepared for their involvement in the recovery process.
Implications for practice
ESD programs should;
1. Consider expanding their therapy at home service to take advantage of the value added to interventions planned within context.
2. Understand the therapeutic benefit of shared intervention space through installation of hope and allowing clients to share
experience and support each other.
3. Consider the importance of the provision of education to families and carers about the support needs required for ESD
participation.
4. Consider the education needs of carers including health literacy, carer support options and carer burden issues that arise when
caring for someone post-stroke.
5. Advocate for the continued provision of home-based therapy in balance with the provision of centre-based care in light of
tightening health care budgets. Acknowledgments
• Dr Mary Kennedy-Jones
• Ms Julie Smith (Eastern Health, ESD Program Co-ordinator)
• Mrs Kate Young
• Eastern Health ESD Clinicians and Health Independence
Program Management
• The 10 participants of this study
Contact details
Mrs Lynda Power: [email protected], Dr Mary Kennedy-Jones: [email protected]
Dr Katherine Harding: [email protected]
Key References
Anderson, C., Rubenach, S., Mhurchu, C. N., Clark, M., Spencer, C., & Winsor, A.(2000a). Home or hospital for stroke rehabilitation? Results of a randomised control trial I: Health outcomes at 6 months. Stroke, 31, 1024-1031.
Askim, T., Rohweder, G., Lydersen, S., & Indredavik, B. (2004). Evaluation of an extended stroke unit service with early supported discharge for patients living in a rural community. A randomized controlled trial. Clinical Rehabilitation, 18(3), 238-248.
Fearon, P., & Langhorn, P. (2012). Services for reducing duration of hospital care for acute stroke patients. Cochrane Database of Systematic Reviews, 9.
Fisher, R. J., Gaynor, C., Kerr, M., Langhorne, P., Anderson, C., Bautz-Holter, E., . . .Walker, M. F. (2011). A consensus on stroke: early supported discharge. Stroke, 42(5), 1392-1397.
“There’s a feeling of camaraderie I suppose … you’re all there because you are not well. But you’re all well enough to understand each other and be conscious of each other” [Kurt]
