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Age and Ageing Advance Access originally published online on October 30, 2007
Age and Ageing 2008 37(1):72-76; doi:10.1093/ageing/afm137
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Copyright © The Author 2007. Published by Oxford University Press on behalf of the British Geriatrics Society.

Older adults and carers' perceptions of pre-discharge occupational therapy home visits in acute care

Anita Atwal1,, Anne Mcintyre1, Christine Craik2 and Jacki Hunt3

1 Lecturer in Occupational Therapy, Mary Seacole Building, School of Health Sciences and Social Care, Uxbridge UB8 3PH, UK
2 Director of Occupational Therapy, School of Health Science and Social Care, Mary Seacole Building, School of Health Science and Social Care, Uxbridge UB8 3PH, UK
3 Head of Occupational Therapy Services for Hounslow PCT, Top Floor, O Block, West Middlesex University Hospital, Isleworth, Middlesex TW7 6AF, UK

Address correspondence to: Anita Atwal. Tel: 01895 268737; Fax: 01895 269853. Email: Anita.atwal{at}brunel.ac.uk


   Abstract
Top
 Abstract
Introduction
 Method
 Results
 Discussion
 Methodological considerations
 Conclusion
 Conflict of interest
 Funding
 Key points
 References
 
Background: pre-discharge occupational therapy (OT) home visits are an integral part of the discharge process for older adults in acute care. There is limited quality research demonstrating that these pre-discharge visits enhance the health and well being of older adults. This paper outlines the perceptions of older adults and carers of the home visit process from the exploratory phase of an ongoing research project.

Method: this qualitative study utilised 22 semi-structured interviews with 15 older adults and 7 carers. Data were analysed using thematic content analysis.

Findings: older adults are not fully prepared to undertake home visits, but carers offer them reassurance about the discharge process. For carers, the home visit process appeared to eradicate anxiety, whilst some older adults perceived the process as demoralising, daunting and increasing their anxiety. In addition, older adults were often reluctant to accept changes or to have valued occupations stopped.

Conclusion: the findings suggest that the current model of pre-discharge home visits does not promote health and well being. For some older adults the home visit provoked anxiety, however home visits are important to carers.

Keywords: pre-discharge home visit, occupational therapy, acute care, carer, older adult, elderly


   Introduction
Top
 Abstract
 Introduction
Method
 Results
 Discussion
 Methodological considerations
 Conclusion
 Conflict of interest
 Funding
 Key points
 References
 
In the acute care setting occupational therapists' key role has evolved to facilitate the discharge process and to undertake pre-discharge home visits [1]. The aim of these home visits is primarily to facilitate a timely, safe and successful discharge from hospital and add to the total picture therapists have of the patient in the real world [2–4]. From an evidence based perspective, there is limited quality research demonstrating that pre-discharge visits enhance the health and well being of older adults in acute care environments [3, 4]. Published research has focused on the practice of home visits, for example, number of visits, grade of therapist, but has not explored in any sufficient detail the home visit decision-making process [5–7]. It is often difficult to compare findings since all the authors [5–7] have devised their own non-standardised survey tools. Patterson et al. [8] highlighted the number of visits performed by therapists in acute care trusts and achieved a good response rate (90%), whilst McDonald et al. [9] found that only 37% of the respondents stated that patients were involved in identifying the need for a home visit. This survey is of interest but it is difficult to determine its quality as the findings of the study have not been published as a long paper. It has been argued that home visits are effective, as older adults are discharged home [7, 10] although the validity of this argument can be questioned because of the lack of control groups in both studies.

Researchers have neglected both the carers' and older adults' perceptions of the home visit process. Two researchers have used qualitative methods to gather older adults' perceptions of the home visit process [11, 12]. Interestingly, both studies found that many participants chose alternative solutions to the problems than those suggested by the occupational therapist. However the methodological quality of both studies is weak, since they fail to give adequate information about the interview process, data analysis and presentation. Indeed, Nygard et al. [12] admit that their study has numerous flaws and should be regarded as a reflective follow-up evaluation.

The rationale for carrying out this study arose from clinical practice and after discussions with numerous occupational therapists and managers who expressed concerns about pre-discharge home visits in acute care.

The aim of the study was to:

  • Explore older adults' and carers' perceptions of the home visit process.
  • Explore older adults' and carers' involvement in decisions that were made during the home visit.


   Method
Top
 Abstract
 Introduction
 Method
Results
 Discussion
 Methodological considerations
 Conclusion
 Conflict of interest
 Funding
 Key points
 References
 
An interpretative approach using 22 semi-structured interviews with 15 older adults and 7 carers was utilised to elicit understanding of older adults' and carers' perceptions of pre-discharge occupational therapy (OT) home visits in acute health care.

The research occurred over 3 months in an acute older adult ward from June until August 2005 in a west London National Health Service (NHS) trust. All older adults aged 65 years and over and their carers who had attended an OT pre-discharge home visit were invited to participate. There were 25 visits during the study duration, performed by 6 occupational therapists in total. In all, 15 older adults agreed to participate in the study and were interviewed, 7 older adults were excluded as they were unable to give consent, 1 older adult withdrew during the study and 2 refused to participate. Most of the older adults who participated in the study were aged 80 years and over (Table 1). Seven of their carers (main person giving support at home) agreed to participate in the study and were interviewed, 3 refused, 2 carers were unable to attend the home visit due to work commitments, and 3 older adults did not have a carer. All seven older adults who were not able to consent had communication difficulties.


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  		Table 1. Patient characteristics

 
Ethics approval for the study was obtained from the Local Research Ethics Committee in March 2005 following NHS REC application procedures. Informed consent was obtained after the older adult and their carer were informed that they would be attending a home visit. A research assistant visited each older adult and carefully explained to all participants the purpose of the visit, before the consent form was signed. The research assistant was a member of the research and development team within the NHS trust and received additional training in interviewing older adults at Brunel University.

The interviews lasted between 20 and 40 min and all the interviews were carried out by the research assistant who used an interview guide (Table 2). Carers were interviewed in a quiet, private room at the hospital, while patients were interviewed at their bedside. All interviews were audio-recorded and transcribed verbatim. The interview schedule was based on literature and the research team's experience of working with older adults in the acute setting.


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  		Table 2. Interview schedule

 
In order to enhance the credibility of the research, participants were asked to comment on the accuracy of the interview transcripts and later they were presented with an analysis of the research findings.

Data were analysed using thematic analysis, which is a method for searching, analysing and reporting themes within data [13, 14]. The phases of thematic analysis included, first, transcribing and reading the data. The second step in analysing the interviews was to conceptualise the data by breaking down each sentence into something that represented an incident [15]. The interview was then coded identifying both latent and manifest themes [16]. These codes were ‘anxiety, preparation, nice, communication, decision making, and change’. Once particular phenomena in the data were identified, their labels were grouped together, referred to as ‘categorising’. Categories that emerged were each given a name, and those that were related to one another were merged. Data analysis produced three major themes, which were related to specific stages of the home visit. The first theme related to the preparation of the home visit. The second theme that emerged related to the communication of outcomes of the home visit and involvement in decision making. The third theme was that of the older adults' and carers' evaluation of the effectiveness of the home visit in meeting individual needs. Two researchers compared and discussed the cluster codes and decided whether the codes were reflected accurately within the themes. A high degree of consensus was found.


   Results
Top
 Abstract
 Introduction
 Method
 Results
Discussion
 Methodological considerations
 Conclusion
 Conflict of interest
 Funding
 Key points
 References
 
Preparation and involvement in the home visit process
Many home visits occurred because carers had expressed concerns about an older adult's level of functioning within the home environment. Indeed older adults voiced their awareness of the process in terms of ‘whether they would be able to return home’, ‘manage’ or ‘cope’. Older adults also regarded it as an opportunity to view their home. They recalled occupational therapists (P8, P9 and P10), nursing staff (P4, P5, P14) physiotherapists (P4, P12) and a doctor (P11) informing them of the home visit, although some older adults could not recall who had informed them (P1, P2, P3, P6, P7, P13 and P15). Some older adults had been given little notification or confirmation about the timing of the home visit; with 24 h notice of the pending visit (P1, P2, P4, P8 and P10), or even ‘last night’ (P7) or ‘that morning’ (P6) being reported by some. One older adult felt that he had no choice: ‘They said I had to go on a home visit, so I went’ (P1).

Commenting on the home visit process, older adults were quick to praise the social skills of therapists and generally felt that home visits were well conducted and the therapists were ‘nice’ (P14) or ‘very helpful’ (P4). Older adults appreciated therapists' ability to enable them to feel comfortable with the pre-discharge assessment process. However some older adults perceived the home visit as a ‘test’ that they could fail. Carers (C4, 7) were generally pleased by the way the occupational therapist motivated the older adult:

‘... she sort of kept saying to him you know you're doing really well, ... she also spoke to me about the little tests that he did here, the stairs and the cuppa tea ... and just said that he's really progressing really well.’ (C9)

Some older adults commented on the speed of the home visit, wanting more time at their home. One older adult did not even have enough time to drink the cup of tea that she had made as a taxi was waiting to return her to the hospital. Another older adult experienced difficulty adjusting to life outside the hospital while on the visit:

‘... you don't realise how slow life is in the hospital and it was quite startling in a way, you know the speed of everything ... it was all over so soon ...’ (P10).

Communication of outcomes and involvement in decision making
The outcome of the visits in terms of being able to ‘manage’ at home was not always communicated to older adults who seemed unsure what would happen next. Some older adults (P11, 12, 13) stated that it was not possible to get a definite answer from professionals. One older adult heard the news about his discharge by roundabout means, ‘I heard someone saying Mr X (patient) is not going home. I don't know why. I heard someone on the phone’ (P13). When information was requested one older adult felt that it was difficult to ascertain future plans and that another assessment would be necessary (P15).

Some older adults did receive instant feedback, with one (P6) being told they would be discharged home that day, (P14) being told that she ‘did well’ and another (P1) being told that they would be discharged the following day. In contrast, other older adults did not appear to have any information or recall any decisions that were made on the home assessment (P2, P10 and P13). Consequently they felt excluded from the decision-making process, saying ‘No they just—um—had a chat between them’ (P7). Likewise, another older adult said, ‘Well, they done a lot of writing but they didn't say a lot to me’ (P5). Another (P10) was aware that the occupational therapist would write a report, but not what would be written. One older adult commented on the speed of the decision-making process on the home visit:

‘It was rather funny because I hadn't been back here half an hour, when one of them came in with a catalogue. All sorts of aids, you know’ (P10)

There was evidence that carers did feel involved in the home visit decision-making process, although sometimes this excluded the older adult.

‘We talked a little while and then the two OTs and I moved to the front room ... Then at the initiation of X (OT), we then all walked back in. In case Y (patient) felt excluded from the conversation.’ (C4)

The effectiveness of the home visit process
Some patients were pleased to have been involved in the home visit, with one saying, ‘I was over the moon’ (P2). Another older adult was content with the positive outcome stating ‘I came away with the feeling that I had succeeded ... yes I felt quite calm and, yes I didn't have any worries at all’ (P10). For one older adult seeing their home had increased their wish to return, ‘I've seen it now and I'm hoping to go back.’ (P12). Other older adults were pleased to make contact with pets and relatives (P7, P5, P6).

There were some instances when older adults expressed negative perceptions about the home visit. One older adult (P4) found receiving negative feedback demoralising and was quite overwhelmed by the whole home visit process:

‘... it puts you down a lot when somebody says, "no Y (patient) you mustn't do that" .... I felt in myself that I had really tried my hardest and that was ... a bit overpowering all/everybody round you. They were all trying to help in their way and that sort of thing, but when you've been in bed and suddenly, do this, do that.’

Others found the home visit anxiety provoking, especially in relation to the therapists' assessment, ‘Oh just nervous at the young lady you know, at what she would say’. (P12.)

Some older adults believed that the home visit was a type of test to be passed or failed.

All of the carers valued the home visit process. One ‘carer stated, It's very good for my blood pressure um; never mind the patient's.’

Another carer said:

‘... you consult the carers and get everything sorted in kind of one morning, yeah, it's useful do you think to have all of you there ... for me it was great, yes .... Also the other day she was talking about she couldn't really remember where she lived. Like what her house was like. So it was kind of good that she came home this morning.’ (C7)

Some older adults considered that too many changes had occurred on the home visit, others seemed resigned to accept the therapists' recommendations, but others resisted the changes made by the occupational therapists. One older adult stated ‘No change .... No, I don't want any change anyway.... I want it as it is ... please’ (P1). Some older adults expressed concerns that the therapist had tried to alter their usual way of performing daily occupations. One older adult recalled an occupational therapist recommending that she did not use the kitchen, something which she could not accept:

‘Oh, I'm told I'm not to go in the kitchen, so how my hairdresser's going to do my hair?’


   Discussion
Top
 Abstract
 Introduction
 Method
 Results
 Discussion
Methodological considerations
 Conclusion
 Conflict of interest
 Funding
 Key points
 References
 
It has been argued that home visits are effective, as older adults are discharged home as a consequence [7, 9]. However the validity of this can be questioned, as there have been no large studies to substantiate these claims. This research gives some insight into how older adults and carers perceive the pre-discharge process in acute care.

The findings from this qualitative research suggest that older adults are not given adequate information about the pre-discharge process. There was evidence that older adults were given little notification of the pre-discharge visit and when informed, some were unable to remember, or were unclear about who had spoken to them about the visit.

The findings from this research support the work by McDonald et al. [9] which found that only a minority of older adults were involved in identifying the need for pre-discharge home visits.

There was little evidence of occupational therapists considering the wider implications of their decision making for clients and carers both in relation to community or social activity, interpersonal interaction and relationships. Indeed, in some cases, meaningful occupations that were important to the client were simply advised to be stopped. Some older adults were unable to perceive the need for, or reluctant to accept changes, and these may be related to the number of changes that were advocated. Mann et al. [17] suggest that almost half the reasons for not using assistive products provided by therapists related to perceived lack of need. Nygard et al. [12] found that occupational therapists perceived that more time was needed at home after discharge for the older adult to discover current need and accept change and this desire for extra time was also commented on in this study by the older people.

The findings from this research suggest that carers valued the pre-discharge home visit process. Many home visits occurred because carers had expressed concerns about an older adult's level of functioning within the home environment. Indeed they could be seen as facilitating discharge, by enabling carers to discuss and voice concerns away from the hospital environment, and feel involved in the decision-making process, with their opinions being listen to. Indeed, the literature identified carers who often rate the quality of planning for discharge much lower than patients as they felt their own needs were not met in relation to the discharge arrangements [18, 19]. Walker and Dewar [20] suggest that indicators of satisfaction for carers were information sharing, involvement in decision making, having someone to contact when needed, and feeling that a service is responsive to needs.

While there was evidence that older adults were satisfied with the social skills of occupational therapists there was evidence that patients did perceive that the therapists were testing them, thus supporting evidence from Clark and Dyer [11]. Within the literature there has been reference to patient anxiety within the context of home assessments [11, 21, 22]. Although there is evidence that older adults do find the home assessment helpful [12], this research suggests that levels of anxiety were prevalent among older adults but not carers.


   Methodological considerations
Top
 Abstract
 Introduction
 Method
 Results
 Discussion
 Methodological considerations
Conclusion
 Conflict of interest
 Funding
 Key points
 References
 
This study explored the perceptions of older adults and carers in relation to the home visit process in one NHS trust only, and therefore the findings cannot be generalised to all other acute care settings. Moreover the sample size is smaller than anticipated as older adults were often unable to participate in the study as consent could not be obtained. For this reason, the use of multi-sites could have assisted recruitment. The building of trusting relationship through introduction to potential participants by familiar or trusted persons, could also have assisted recruitment [23]. The individual skills and expertise of the occupational therapists involved could have affected the opinions of carers and older adults. In addition, the capture of demographic data could have added richness to the data.


   Conclusion
Top
 Abstract
 Introduction
 Method
 Results
 Discussion
 Methodological considerations
 Conclusion
Conflict of interest
 Funding
 Key points
 References
 
The findings from this research suggest that older adults are not fully prepared to undertake home visits, but offer carers reassurance about the discharge home. While the long-term benefits of home visits are not known it is essential to re-think the rationale for carrying out pre-discharge home visits. The timing of home visits needs to be carefully considered, both in terms of when they take place and duration, and it is suggested that therapists need to ensure that older adults have reached their maximum level of independence prior to taking part in a home visit.


   Conflict of interest
Top
 Abstract
 Introduction
 Method
 Results
 Discussion
 Methodological considerations
 Conclusion
 Conflict of interest
Funding
 Key points
 References
 
None


   Funding
Top
 Abstract
 Introduction
 Method
 Results
 Discussion
 Methodological considerations
 Conclusion
 Conflict of interest
 Funding
Key points
 References
 
Study Funding: £ 10,000 Hounslow PCT R&D

The sponsors played no role in the design, execution, analysis and interpretation of the data.


   Key points
Top
 Abstract
 Introduction
 Method
 Results
 Discussion
 Methodological considerations
 Conclusion
 Conflict of interest
 Funding
 Key points
References
 

  • OT pre-discharge visits offer carers reassurance about the discharge process and can eradicate anxiety.
  • Older adults can find a home visit experience demoralising, daunting and anxiety provoking due to weak communication, preparation and involvement in the decision-making process.
  • Pre-discharge home visits should only occur in acute care cases once the older adult has reached their optimum level of function in all activities of daily living.


   References
Top
 Abstract
 Introduction
 Method
 Results
 Discussion
 Methodological considerations
 Conclusion
 Conflict of interest
 Funding
 Key points
 References
 

  1. McEneany J, McKenna K, Summerville P. Australian occupational therapists working in adult physical dysfunctional settings. What treatment media do they use? Aust Occup Ther J (2002) 3:170–7.
  2. Durham D. Occupational and physical therapists' perspective of the perceived benefits of a therapeutic home visit program. Phys Occup Ther Geriatr (1992) 3:15–33.
  3. Roughton F. Why do Occupational Therapists Carry out Pre-Discharge Home Visits with Hospital in-Patients? (2004) An investigation using the Delphi Technique. MSc in Health Through Occupation, University of Brighton, Faculty of Health, School of Health Professions.
  4. Watson L. Why so Occupational Therapists Carry-Put Pre-Discharge Home Visits with Hospital In-Patients. (2004) MSc in Health Through Occupation. University of Brighton, Faculty of Health, School of Health Professions.
  5. Patterson CJ, Mulley GP. The effectiveness of predischarge home assessment visits: a systematic review. Clin Rehabil (1999) 2:101–4.
  6. Barras S. A systematic and critical review of the literature: The effectiveness of occupational therapy home assessments on a range of outcome measures. Aust Occup Ther J (2005) 4:326–36.
  7. Whitaker JJ, Hornby J. A review of home visits by occupational therapists in a geriatric assessment unit. BJOT (1986) 11:365–6.
  8. Patterson CJ, Viner J, Saville C, et al. Too many pre-discharge home visits for older patients? A postal questionnaire survey. Clin Rehabil (2001) 3:291–5.
  9. McDonald RE, Chesson RA, Burnett G, et al. Pre-discharge home assessment visits with elderly patients. Collaborative study of current practice. Physiotherapy (2003) 5:323.
  10. Renforth P, Yapa RS, Forster DP. Occupational therapy predischarge home visits: A study from a community hospital. BJOT (2004) 11:488–94.
  11. Clark H, Dyer S. Equipped for going home from hospital. Health Care Later Life (1998) 1:35–45.
  12. Nygard N, Grahn U, Rudenhammer A, et al. Reflecting on practice: are home visits prior to discharge worthwhile in geriatric inpatient care. Scand J Caring Sci (2000) 18:183–203.
  13. Braun V, Clarke B. Using thematic analysis in psychology. Qual Res Psych (2006) 3:77–1, 1.[CrossRef]
  14. Fereday J, Muir-Cochrane E. Demonstrating rigor using thematic analysis: A hybrid approach of inductive and deductive coding and theme development. IJQM (2006) 5:1–11. Article 7. Retrieved 8.04.2007 from http://www.ualberta.ca/~iiqm/backissues/5_1/html/fereday.htm.
  15. Strauss A, Corbin J. Basics of Qualitative Research. (1990) Newbury Park: Sage.
  16. Miles MB, Huberman AM. Qualitative Data Analysis. (1994) 2nd edition. Thousand Oaks: Sage.
  17. Mann WC, Goosall S, Justiss MD, et al. Dissatisfaction and nonuse of assistive devices among frail elders. Assist Technol (2002) 2:130–9.
  18. Jones D, Lester C. Hospital care and discharge: patients' and carers' opinions. Age Ageing (1994) 32:91–6.
  19. Grimmer KA, Modd JR, Gill TK. Discharge planning quality from the carer perspective. Qual Life Res (2000) 9:1005–13.[CrossRef][Web of Science][Medline]
  20. Walker E, Dewar JB. How do we facilitate carers' involvement in decision making? J Adv Nurs (2001) 3:329–37.
  21. Waite R. Home Visits: Older Peoples' Experience within the Phased Discharge Process. (2004) MSc in Health Through Occupation, University of Brighton, Faculty of Health. School of Health Professions.
  22. Bore J. Occupational therapy home visits: A satisfactory service? BJOT (1994) 3:85–8.
  23. Gueldner SH, Hanner MB. Methodological issues relating to gerontological nursing research. Nurs Res (1989) 38:183–5.[Web of Science][Medline]
Received 8 January 2007; accepted in revised form 27 June 2007.


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This Article
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