Learning from ‘Experts’ at Canadian Stroke Rehabilitation Distinction Sites: Implications for the Management of Patients with Complex Care Needs

Background: Health care systems use standardized approaches to effectively reduce costs and deliver high-quality care. However, there is a growing subset of “complex” patients whose care trajectories deviate from the expected clinical pathways. These patients often require customized care to address their multiple concurrent health and social issues. In stroke rehabilitation settings, clinicians provide care for a high proportion of patients with complex care needs. At Canadian Stroke Distinction sites, clinicians provide measurably excellent care in accordance with the Stroke Rehabilitation Best Practice Recommendations (SRBPR), despite the limited applicability of these recommendations for complex care needs. Methods: The primary purpose of this thesis was to understand how expert stroke rehabilitation clinicians recognize and manage the care for patients with complex care needs. A secondary aim was to explore how clinicians developed the expertise to manage the care of these patients. To address these aims, we (1) conducted a critical appraisal of professional competency frameworks for stroke rehabilitation clinicians, to assess the degree of guidance for managing complexity in practice; (2) conducted an interpretive description study, which explored the perspectives of stroke rehabilitation clinicians, organizational and health system key informants; (3) conducted a critical appraisal of the SRBPR to locate recommendations relevant to the care of patients with complex care needs. Findings: There is minimal guidance in macro-level sources (e.g., competency frameworks, SRBPR) to support clinicians in caring for patients with complex needs. From interviews, we learned that (1) recognizing complexity is routine work for clinicians, (2) clinicians used workarounds to manage complexity, and (3) clinicians perceived and worked to bridge a difference between organizational processes and the realities of patient care. We noted misalignment between clinician perceptions of most patients as complex, and organizational efforts to plan for complexity, which estimate 20% of patients to be complex. Conclusion: There is a need to better define and account for the needs of patients deemed as complex, at macro- and meso-levels, in ways that support clinicians to better leverage their expertise in care delivery.

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