Which are the factors that influence the provision of home-based rehabilitation services for people needing rehabilitation?

Epidemiologic studies estimate that 15% of the world’s population lives with disabilities and that 2.4 billion people require rehabilitation. These numbers will rise due to the growing and ageing population and the increasing disease complexity and chronicity. In this scenario, rehabilitation services should respond to the increasing demand for long-term disease management and aim to increase mobility, cognition, sensory functions, and well-being. Contextual factors, such as social and environmental, can be determinants in access to rehabilitation services. As stated in the International Classification of Functioning, Disability and Health (ICF), these contextual factors may act as facilitators or barriers. The 2020 COVID-19 pandemic, as access to rehabilitation services, was even more limited, exposed the need to expand the systems of delivery of services to an already vulnerable population. Home-based rehabilitation and telerehabilitation are strategies that may be adopted when other modes of services are limited or not possible. In-person home-based rehabilitation refers to the delivery of services where the patient lives and involves learning strategies for the caregiver and for self-management, exercise training, counselling, and environment modification. Telerehabilitation can be a mode of home delivery that employs the use of information and communication technologies without the physical presence of the healthcare professional. Implementation of these services not only may expand access to home-bound patients but also cuts the cost burden and travel, while delivering rehabilitation in a familiar environment. Drawbacks of this method of delivery may be difficulties in adherence and equipment setup and use. Furthermore, internet and electricity resources may not readily be available in certain low-income remote settings.

This review aimed to analyze qualitative evidence on the factors that influence the organization and delivery of home-based rehabilitation and telerehabilitation services for people with disability.

This review is important for

People living with disability experience restricted access to services, their loved ones/caregivers, health professionals caring for this population, general practitioners, researchers, and policymakers.

Outcomes of this review

This is a new Cochrane Systematic Review (CSR) published in 2023. The review analyzed studies that used qualitative methods for data collection and analysis and that explored the experiences of patients, caregivers, healthcare providers, and other stakeholders’ perceptions and behaviours about the provision of in-person home-based rehabilitation and home-based telerehabilitation services. The CSR sampled 53 studies out of 223 published and/or registered up to June 16, 2022. Results showed that home-based rehabilitation services delivered in person or through telerehabilitation were perceived as convenient and empowering; on the other hand, there is less privacy and confidentiality when services are provided at home. Patients and providers also describe other factors that probably influence rehabilitation, such as support and communication from providers and family, the patient’s needs and comorbidities, and the transition from hospital to home-based services.

Telerehabilitation was perceived as an additional opportunity to provide services, but providers found it difficult to assess the correct execution of exercises and highlighted the lack of equipment and proper environment as well as interruptions from family members. On the other hand, patients reported frustration and difficulties in the use of digital technology, suggesting a need for more training and support with at least some in-person sessions with the provider.

Providers had mixed opinions about the cost-effectiveness of telerehabilitation, but many patients rated the intervention as cost-saving if equipment and infrastructure were provided.

Patients and providers reported that telerehabilitation can change the very nature of their relationship. On the one hand, this may lead to easier and more informal communication, whereas on the other it may lead to patients feeling abandoned, making meaningful connections more difficult. In some cases, the contact and the necessity of providers’ hands cannot be overcome, and providers underlined the importance of an individualized program for each person’s needs. These results must be interpreted with caution because most of the studies (i) did not provide information on whether home-based rehabilitation was provided instead of an available in-patient service or whether it was the patient’s only option. (ii) No studies looked at people’s experiences and perceptions in the long term, which could be relevant because most conditions that lead to disability have a chronic progression. (iii) No studies included conditions such as Parkinson’s disease or amputations, even if these are important targets for intervention. (iv) Studies were mainly conducted in high-income countries where the availability and organization of services could be extremely different from middle- and low-income countries. (v) The authors did not search CINHAL database, possibly excluding relevant studies. (vi) The authors did not translate six studies, which may lead to a sampling error, even if in the author's opinion it was not significant.

Author’s conclusion of the review

This qualitative review synthesized several pros and cons of in-person home-based rehabilitation and telerehabilitation that may be considered in their implementation. Healthcare providers and policymakers might take advantage of the present synthesis when designing intervention programs. In particular, the authors suggested considering who may benefit the most from telerehabilitation, to assess individuals’ needs, accessibility, availability to services, and their home environment. Moreover, these kinds of interventions may be important as part of the continuity of care from hospital to home setting. The authors suggest also that policymakers should inquire about the actual cost-effectiveness of these interventions, taking into account transport and time costs, equipment, and technical support. They should also consider how these interventions give people more control over their bodies and life, empowering them in the rehabilitation process.  On the other hand, home-based rehabilitation raises the issue of privacy and confidentiality of patients and families when providers are in their homes. Telerehabilitation can change the very nature of the patient-provider relationship, which is debated to be easier and more information on one hand, whereas, on the other, it may lead to patients feeling abandoned, making meaningful connections more difficult.

Future recommendations

The authors recommended that future qualitative and mixed-method studies should (a) report their methods thoroughly, especially for participant recruitment, data collection, and ethical issues. (b) The authors should consider and declare plainly how their own opinions might affect qualitative data interpretation. (c) Research should also come from low- and middle-income countries and their settings. (d) Moreover, research should investigate the perception of treatment after hospital rehabilitation as compared to that provided instead of hospital treatment or as the only possible option. (e) Further studies should also inquire into health-system factors that may act as facilitators or barriers for the transition from hospital to home-based rehabilitation services. (f) Authors should also explore the training and education requirements of patients and providers and (g) motivation and short- and long-term outcomes compared to in-patient rehabilitation.

Robin Kuruvila Sentinella