Samenvatting

Background There is a shift from inpatient to home-based geriatric rehabilitation (HBGR), and potential benefits are demonstrated. Previously, a theoretical HBGR model, version 1.0, has been developed, outlining its essential components. However, clear guidance on the practical design and organisation of HBGR in everyday practice is still lacking. Therefore, determining the optimal design for this complex intervention is essential for its successful implementation in daily practice. The objective of this study is to redesign the theoretical HBGR trajectory and assess its feasibility, acceptability, and usability from both patient and professional perspectives. Methods A redesign and feasibility study based on the MRC framework was conducted in a Dutch skilled nursing facility using the MRC framework in co-creation with eleven healthcare professionals and four patient representatives. The HBGR trajectory 1.0, comprises four building blocks (structure, process, environment, and outcomes) based on the Post-Acute-Care rehabilitation quality framework. Version 1.0 was redesigned during the development phase and subsequently pilot-tested in daily practice during the feasibility phase. Adjustments were made based on semi-structured interviews with ten patients and (interim) evaluations. Results The HBGR trajectory 1.0 has been redesigned into version 2.0. It contains eleven elements: individualised goal setting, providing HBGR is the default unless otherwise indicated, an information letter, blended eHealth, mapping the patient’s living environment, stimulation support from informal caregivers, collaboration with community care nursing, rehabilitation coordination, central planning, therapy at home, and online multidisciplinary evaluation. Version 2.0 was enthusiastically endorsed by patients, patient representatives, and professionals, who found it feasible, acceptable, and usable in daily practice. Conclusion The HBGR trajectory 1.0 was adapted, tested, and finally redesigned into version 2.0. The study revealed that involving patients, their representatives, and healthcare professionals was critical to garnering support and facilitating implementation. Key developments align with global trends and include the successful integration of eHealth with traditional treatment methods, enhanced collaboration and knowledge sharing among community care nurses, and increased involvement of informal caregivers in rehabilitation. This redesigned HBGR trajectory is ready for evaluation and implementation in follow-up effectiveness research.