Abstract
BackgroundEach year, approximately 100,000 individuals receive home health services after a stroke. Evidence has shown the benefits of home-based stroke rehabilitation, but little is known about resource-efficient ways to enhance its effectiveness, nor has anyone explored the value of leveraging low-cost home health aides (HHAs) to reinforce repetitive task training, a key component of home-based rehabilitation. We developed and piloted a Stroke Homehealth Aide Recovery Program (SHARP) that deployed specially trained HHAs as “peer coaches” to mentor frontline aides and help individuals recovering from stroke increase their mobility through greater adherence to repetitive exercise regimens. We assessed the feasibility of SHARP and its readiness for a full-scale randomized controlled trial (RCT). Specifically, we examined (1) the practicability of recruitment and randomization procedures, (2) program acceptability, (3) intervention fidelity, and (4) the performance of outcome measures.MethodsThis was a feasibility study including a pilot RCT. Target enrollment was 60 individuals receiving post-stroke home health services, who were randomized to SHARP + usual home care or usual care only. The protocol specified a 30-day intervention with four planned in-home coach visits, including one joint coach/physical therapist visit. The primary participant outcome was 60-day change in mobility, using the performance-based Timed Up and Go and 4-Meter Walk Gait Speed tests. Interviews with participants, coaches, physical therapists, and frontline aides provided acceptability data. Enrollment figures, visit tracking reports, and audio recordings provided intervention fidelity data. Mixed methods included thematic analysis of qualitative data and quantitative analysis of structured data to examine the intervention feasibility and performance of outcome measures.ResultsAchieving the 60-participant enrollment target required modifying participant eligibility criteria to accommodate a decline in the receipt of HHA services among individuals receiving home care after a stroke. This modification entailed intervention redesign. Acceptability was high among coaches and participants but lower among therapists and frontline aides. Intervention fidelity was mixed: 87% of intervention participants received all four planned coach visits; however, no joint coach/therapist visits occurred. Sixty-day follow-up retention was 78%. However, baseline and follow-up performance-based primary outcome mobility assessments could be completed for only 55% of participants.ConclusionsThe trial was not feasible in its current form. Before progressing to a definitive trial, significant program redesign would be required to address issues affecting enrollment, coach/HHA/therapist coordination, and implementation of performance-based outcome measures.Trial registrationClinicalTrials.gov, NCT04840407. Retrospectively registered on 9 April 2021
Highlights
Each year, approximately 100,000 individuals receive home health services after a stroke
To tap into this resource, would require that selected aides receive additional training and support beyond the Medicare-required 75 h of entry-level training, with its limited focus on therapeutic activities or stroke [32]. This would likely be impractical given high training costs, the need for intensive hands-on skill building, and the challenge of finding substitute aides to provide ongoing assistance to individuals when their usual aides were in coach training. Addressing these constraints, we developed the Stroke Homehealth Aide Recovery Program (SHARP) to prepare a select group of frontline health aides (HHAs) to become “peer coaches” who would support other frontline aides in the field
SHARP recruitment and randomization procedures Coaches HHA supervisors and training staff prescreened and referred 18 coach candidates to be interviewed for coach training
Summary
Approximately 100,000 individuals receive home health services after a stroke. We developed and piloted a Stroke Homehealth Aide Recovery Program (SHARP) that deployed specially trained HHAs as “peer coaches” to mentor frontline aides and help individuals recovering from stroke increase their mobility through greater adherence to repetitive exercise regimens. Individuals recovering from stroke are the second most common users of publicly funded post-acute rehabilitation services across all settings. They account for more than 475,000 people a year [2]. 100,000 individuals receive home-based poststroke services paid for by Medicare, the health insurance program for US residents 65 years of age or older [3]. For many individuals, improved mobility is a primary goal of rehabilitation [12]
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