Development and description of Early Stroke Specialist Vocational Rehabilitation delivered in the RETAKE trial.

OBJECTIVE

This paper describes the development of an Early Stroke Specialist Vocational Rehabilitation intervention to support return to work following stroke and its delivery in the RETAKE trial.

METHODS

Iterative three stage, target population approach to intervention development and evaluation informed by the Medical Research Council Framework. Stage 1 (Initial codevelopment): interviews with key stakeholder service providers and users' and mapping of services supporting return to work after stroke to identify and explore barriers to and unmet needs for support; intervention codevelopment with experts and patient and public involvement (PPI). Stage 2 (Refinement): expert panel codevelopment workshops and systematic review to identify vocational rehabilitation intervention mechanisms of change in supporting return to work after stroke. Stage 3 (Testing): intervention piloting in two case studies, feasibility testing in a randomised controlled trial, acceptability interviews with stroke and employer participants. Further intervention refinement following delivery in the RETAKE randomised controlled trial.

RESULTS

Stage 1: service mapping and 25 stakeholder interviews identified service gaps and unmet needs relating to early identification of employed stroke survivors, mild stroke, and hidden disabilities. Access to timely support relied on geographical proximity to a specialist hub and tacit knowledge of complex health, education and employment services and provider roles. Return to work issues reported by stroke survivors informed Early Stroke Specialist Vocational Rehabilitation prototype design objectives. Iterative developments following piloting included fatigue management, involvement of general practitioners, work simulation and liaison with other healthcare services. Interviews with 12 recipient stroke survivors and 6 employers identified additional features including occupational therapist negotiation skills, ability to respond to changing needs over time and patient empowerment to self-re-refer. The review corroborated intervention components and mechanisms and identified additional mechanisms, for example, peer support, supported self-management. Intervention mechanisms identified across the three stages were early intervention, understanding the impact of stroke on the person, their job and work environment, vocational goal setting, implementing workplace accommodations, individual tailoring, work preparation, colocation, case co-ordination, Multidisciplinary Team (MDT) working, employer engagement and education, and responsiveness, which involved monitoring work stability, providing feedback, and responding to changing needs over time and participant self-re-referral. In RETAKE, Early Stroke Specialist Vocational Rehabilitation was successfully delivered to 95.4% of allocated participants with 75.3% compliance. Intervention commenced a median 38 days (interquartile range 23-56, range 6-216) post stroke and continued for ≤ 12 months. Participants had a median seven intervention sessions (interquartile range 4-12, range 0-37), with discharge a median 10.3 months (interquartile range 5.5-12.0, range 0-15.4) post randomisation. Most intervention sessions were delivered via telerehabilitation (51.7%), in participants' homes (35.9%) or workplaces (6.4%). There was little difference between the number of sessions offered [mean 9.6 (standard deviation 7.46, range 0-39)] and attended [mean 9.0 (standard deviation 7.16), range 0-37]. However, occupational therapist contact with employers only occurred for 109 (36.8%) participants and employer visits occurred for 74 (25.0%). The Early Stroke Specialist Vocational Rehabilitation focus changed between the feasibility and definitive trial, with greater emphasis on current issues, fatigue management and informal psychological support, possibly due to the coronavirus disease discovered in 2019 pandemic. A programme theory and logic model illustrating the refined intervention and a description of Early Stroke Specialist Vocational Rehabilitation delivered in the RETAKE trial is reported.

CONCLUSION

This comprehensive description of Early Stroke Specialist Vocational Rehabilitation will enable occupational therapists to implement Early Stroke Specialist Vocational Rehabilitation in practice and facilitative future evaluation.

FUNDING: This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number 15/130/11.