Title: Assessment of rehabilitation potential in frail older people in the acute healthcare setting: a mixed methods study.
Funder: Health Education England

Abstract: Title Assessment of rehabilitation potential in frail older people in the acute healthcare setting: a mixed methods study. Background People over the age of 80 are now the fastest growing group in the UK. The prevalence of health problems increases with age and consequently the absolute number of older people with complex co-morbidities, functional dependence and cognitive dysfunction presenting to health and social care services has increased. There is compelling evidence from a systematic review that when older people living with frailty receive treatments such as Comprehensive Geriatric Assessment (CGA), they experience physical, cognitive and functional decline at lower rates than control subjects. CGA includes rehabilitation treatments which are cited as a key component in the management of frailty and in meeting older people's complex and diverse needs. However not all patients are deemed suitable for the rehabilitation component of CGA as they have been classified as being unlikely to benefit from rehabilitation treatments by healthcare professionals. This is sometimes referred to as having no rehabilitation potential, a term frequently used by clinicians in day-to-day clinical practice. Being deemed to have rehabilitation potential or not, is critical to the amount and types of rehabilitation a patient will receive and can result in patients being denied access to services which may be beneficial. Evidence is currently lacking about how health professionals assess rehabilitation potential, their underlying decision-making process and who will benefit most from rehabilitation. It is also not clear what factors influence these decisions, what is deemed a good' outcome and how potential for improvement is assessed. Aims The aim is to define and understand the term rehabilitation potential and then develop and test an assessment tool that will identify rehabilitation potential in older people living with frailty. Define what is meant when the term rehabilitation potential' is used older people living with frailty. Explore the rationale behind the use of the term and why it is used in clinical settings. Identify how clinicians currently assess rehabilitation potential. Identify what factors influence the decision that people do or do not have rehabilitation potential. Explore how patient, carer and family views on rehabilitation potential are taken into account. Develop a patient-centred rehabilitation potential assessment tool. Test the feasibility of using the rehabilitation potential tool in a clinical setting. Plan of investigation A sequential exploratory mixed methods study is proposed with four components which build upon each other: Component A: Mapping Review to identify and map relevant literature that can be used to develop an evidence-based assessment tool. Component B: Focus Groups - to explore the opinions, experiences and understanding of rehabilitation potential from multiple perspectives to gather data that will be used to develop the assessment tool. Component C: Tool Development and Consensus Approach- The core supervision team will use the findings from the focus group work to develop a draft assessment tool which will be refined using a modified two-step Delphi consensus approach to ensure that the components are relevant and applicable. Component D: Feasibility Study - to test whether the assessment tool can be delivered in the acute NHS healthcare setting. This will include measuring if it is acceptable to patients, carers and clinicians and inter-rater reliability. Benefits to patients and NHS The development of an evidence-based assessment tool to identify rehabilitation potential in older people living with frailty would allow for a more consistent and transparent decision-making process which is responsive and patient-centred. By taking into account individual patient needs, rehabilitation services can be effectively designed in terms of capacity and responsiveness to meet the needs of the growing elderly population.

Lay abstract: Aims This study aims to develop and test an assessment tool that will identify rehabilitation potential in older people in the hospital setting. Background People over the age of 80 are now the fastest growing group in the UK, so the number of older people with complex health and social needs has increased. Older people have more hospital admissions than young people, longer lengths of stay, greater use of social care and frequently have poorer outcomes. There is strong evidence that when older people with complex health and social needs receive Comprehensive Geriatric Assessment (CGA), they are less likely to experience further changes to their physical, cognitive and functional abilities. CGA looks at all the issues which can affect health. It includes a review of medicines, physical capability, mental capability and social factors and, in conjunction with the patient and carer, seeks to suggest changes which could improve the day-to-day wellbeing of the patient including rehabilitation. Traditionally rehabilitation has focused on restoring previous function, but, different approaches may be more appropriate for older people with complex needs. Therapists may have limited time to assess and work with patients and carers in a busy hospital environment and the complexities of ageing may not always be fully appreciated. The term 'rehabilitation potential' is frequently used by health professionals in their day-to-day work. Being deemed to have rehabilitation potential or not is critical to the amount and types of rehabilitation that are offered and can result in patients being denied access to services. Evidence is currently lacking about how health professionals assess rehabilitation potential, specifically their decision-making process. Understanding how potential is assessed, what is deemed a good' rehabilitation outcome, what types of rehabilitation are offered and when to continue or stop rehabilitation would facilitate a more patient-centred approach to care. Design and Methods The study will have four components: 1. Component A will use a review of the published literature to explore what is meant by the term rehabilitation potential', how it is assessed by health professionals and what is deemed a good' outcome of rehabilitation. 2. Component B will use focus groups comprising service users, carers and health professionals to explore their opinions, experiences and understanding of rehabilitation potential to gather information that will be used to develop the assessment tool. 3. Component C will use a Delphi approach incorporating the use of electronic questionnaires with an expert panel to facilitate the development of the assessment tool and a computer aided learning package by the supervision group and public collaborator. Participants will be asked to rate the extent to which they agree/disagree on the content of the assessment tool using a validated scale. 4. Component D will comprise a feasibility study to look at the acceptability and tolerability of the assessment tool and computer learning package from the perspective of health professionals, patients and carers. Patient and Public Involvement The topic area, question, methods and dissemination plan have been developed following consultation with members of the Dementia, Frail Older People and Palliative Care PPI advisory Group at the University of Nottingham and Age Concern Day Centres. Margaret Kerr (PPI collaborator) has reviewed this application and will continue to advise and shape the study in the following ways: Developing the focus, interview questions and interview guide to ensure they are clear and fit for purpose. Developing the participant information sheet to ensure that the language is appropriate. Reviewing findings from the focus group with the academic supervisors, providing a differing view point. Contributing to the development of the rehabilitation potential assessment tool. Dissemination The study will form the basis for my PhD. Findings will be shared with patients, carers, members of the public, health professionals and service commissioners in the following ways: Two videos explaining the background and findings of the study will be produced for members of the public and health professionals, which will be shared using social media. Findings will be shared in peer-reviewed journals, clinical conferences and meetings within hospital and community health services. A newsletter will be developed with members of the PPI group for circulation to the study participants and members of the public. A computer aided learning package will be produced with communication experts at the University of Nottingham to help train health professionals in the use of the rehabilitation potential assessment tool.

Research activity codes: 7.2 END OF LIFE CARE
Health categories: GENERIC HEALTH RELEVANCE