Facilitators and barriers to implementing new models of care for patients in a rehabilitation care setting: A systematic review

Abstract

Introduction

This systematic review aimed to synthesize evidence on the key findings of evaluations of implementation of models of care in rehabilitation and describe facilitators and barriers to implementing new models of care.

Method

Six electronic databases were searched. Abstracts and full texts were screened and critically appraised. Facilitators and barriers were classified using the Consolidated Framework for Implementation Research version 2.0.

Results

Of the 64 studies identified, 52 (81%) were new care models implemented in a hospital and 12 (19%) were situated in a home or community-based setting. Common implementation evaluation metrics reported included fidelity (n = 15), adherence (n = 16), feasibility (n = 14), and acceptability (n = 12). Facilitator domains were innovation source (e.g., uncomplicated models), outer setting (e.g., positive attitude), inner setting (e.g., teamwork or motivation), individuals (e.g., skill) and implementation (e.g., planning according to need and context). Barrier domains were innovation source (e.g., model complexity), outer setting (e.g. .organisational culture), inner setting (e.g., staff turnover, training, or resources,), individuals (e.g., no champions) and implementation (e.g., lack of planning).

Conclusions

The review highlights the importance of planning before implementing new models of care in rehabilitation settings to address potential facilitators and barriers in a real-world environment.

Keywords

barrier care model consolidated framework for implementation research CFIR facilitator implementation rehabilitation

Introduction

According to the World Health Organization (2023), 2.4 billion people worldwide have a chronic health condition that could benefit from some form of rehabilitation.¹ Rehabilitation as a result of a chronic disease or injury involves an individual participating in a series of interventions (i.e., a care delivery model) that aim to reduce disability and optimise function.¹ Rehabilitation often enables an individual to be as independent as possible in their activities of daily living, and enables their participation in social, work, educational, and other activities.¹ In Australia, one in two people are estimated to have a chronic health condition,² accounting for two-thirds of the total burden of disease and injury.³ Injury alone accounts for 7.6% of medical costs and 8.1% of the disease burden.⁴ With the increasing demand for rehabilitation services and finite resources, new models of care that can both aid recovery and support access and ease of delivery are being implemented and trialled.^5–7

Rehabilitation is a crucial component of the healthcare system that can assist people to regain their physical functioning after sustaining an injury or disease.¹ The provision of rehabilitation services can be influenced by many factors, such as the available healthcare infrastructure, funding mechanisms, prioritisation, accessibility of rehabilitation services, availability of health professionals, and resources.⁸ Determining what factors are critical for the successful implementation and delivery of rehabilitation services, including the implementation of new rehabilitation care models, will support successful implementation of new care models across different rehabilitation settings.

Rehabilitation practices are constantly evolving, with new care models being introduced and evaluated.^9–11 Rehabilitation can be provided in locations such as inpatient, outpatient, in the home or community-based settings.^12,13 Care models may be applicable across several settings, yet what factors contribute to the successful implementation of new care models across rehabilitation settings are not widely reported. It is important to identify factors that can aid implementation of rehabilitation care models in real-world settings.

Evaluating the implementation of a new care model has the ability to shed light on how closely the delivered care aligns with the intended model (adoption), how closely the implementation resembled what was planned (fidelity), how many individuals received care under the new model (reach), how appropriate the care model is for patients and health professionals (acceptability), the cost-effectiveness of implementing the new model, and the feasibility and sustainability of the care model long-term.¹⁴ Evaluating care model implementation can assist in drawing attention to areas that require improvement. Identifying facilitators and barriers to the implementation process can also aid in the identification of what works, or does not work well, and why. However, an awareness of factors that can aid or hinder implementation of new care models in rehabilitation settings is lacking.

Previous studies have examined the implementation of care models for individuals undergoing rehabilitation.^14–17 However, little has been reported on the evaluation of the implementation of new care models in a rehabilitation setting across health conditions. There may be opportunities to learn from different approaches in implementing care models across rehabilitation settings and to identify common barriers and facilitators to implementation that would aid the planning for the implementation of new care models for rehabilitation. The aim of this systematic literature review was to synthesise evidence on the evaluation of the implementation of new models of care in rehabilitation and describe facilitators and barriers to implementing new models of care for patients in a rehabilitation care setting.

Methods

This systematic review adhered to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement.¹⁸ The review protocol was not pre-registered.

Definitions and conceptual model

For this review, rehabilitation was considered to be a set of interventions used to reduce and optimise the limitations or disability of an individual with a physical health condition (excluding drug and alcohol rehabilitation and interventions related to mental disorders), and could take place in hospital, in the community or in the home.¹ A model of care describes a best practise approach for the delivery of care, often using a care guideline or protocol.¹⁹ For this review, a new model of care was considered as the introduction of a model of care that includes either one or more new interventions into a rehabilitation setting, or the introduction of one or more existing interventions that had not previously been implemented in a rehabilitation setting, excluding virtual care models.

The term ‘implementation’ in healthcare describes the process of putting evidence-based interventions into best practice.^20,21 Implementation for this review was defined as specific strategies, measures, or methods of a rehabilitation program that were intended to be delivered using a model of care. Implementation evaluation measures considered included adoption, acceptability, appropriateness, feasibility, fidelity, implementation cost, reach, penetration, and sustainability (Supplemental file 1). Barriers to implementation were considered to be challenges that had a negative impact on the introduction of a new model of care, whereas facilitators to implementation were considered to be factors that supported the introduction of a new model of care.²¹ In this review, the same components could be coded as barriers or facilitators depending on their observed effect on implementation.

The revised Consolidated Framework for Implementation Research (CFIR) was utilised to categorise the facilitators and barriers identified.²² The CFIR is a meta-theoretical framework that can be used to identify contextual determinants of an implementation process. It includes five major domains¹: innovation (e.g., innovation source, evidence based, relative advantage, adaptability, trialability, complexity, design and cost);² outer settings (e.g., critical incidence, local attitudes, local conditions, partnerships and connections, policies and laws, financing, external, social and market pressure, performance measurement pressure);³ inner settings (e.g., structural characteristics, relational connections, communications, culture, tension for change, compatibility, relative priority, incentive system, mission alignment, available resources, access to knowledge and information);⁴ individuals (e.g. high level, mid-level and opinion leaders, implementation facilitators, leads and team members, other implementation support, innovation delivers and recipients);⁵ and implementation process (e.g. teaming, assessing needs, assessing context, planning, tailoring strategies, engaging, doing, reflecting and evaluating and adapting). For this review, any subdomains of CFIR were classified under the related domains and constructs.

Data sources

Six electronic databases were searched from 1 January 2000 to 14 March 2025: CINAHL (EBSCOhost), MEDLINE (Ovid), AMED (Ovid), Embase (Ovid), Scopus, and Web of Science. The search strategy was developed with a university research librarian, and keywords related to the following key concepts: (a) rehabilitation; (b) model of care; (c) implementation; and (d) evaluation. Search terms for the key concepts were combined using the Boolean operators (Supplemental files 2-7). Additional relevant articles were identified by backwards citation tracking of the reference lists of included studies.

Eligibility criteria

Studies were selected based on the following eligibility criteria. Inclusion criteria were studies that: (a) evaluated or described the implementation of a new model of care in rehabilitation settings (e.g., hospital-, community-, and home-based); (b) identified any barriers or facilitators during the implementation of the new model of care; (c) were original research articles, clinical trials, qualitative or quantitative or mixed methods studies; and (d) included an adult population aged ≥18 years. Exclusion criteria were studies that: (a) were published in languages other than English; (b) were published before 2000; (c) described the development or validation of a measure (e.g., clinical tool, guideline) and its impact on patient outcomes, but did not describe any implementation measures and strategies; (d) included a paediatric population aged <18 years; (e) that evaluated drug and alcohol rehabilitation, vocational rehabilitation, and care delivery models or interventions related to mental disorders; (f) evaluated the introduction of virtual care models or telerehabilitation models; (g) evaluated an intervention or care model that included pre-operative interventions where the rehabilitation setting could not be specifically examined; (h) evaluated adherence to existing clinical guidelines; and (i) were review articles, study protocols, conference abstracts and papers, books, book chapters, theses, case reports, and case series.

Study selection process

The full citation information including title and abstract of each article identified from the search strategy was imported into Endnote X20 (Clarivate, London, United Kingdom) and duplicates removed. Unique records were imported into Covidence (Veritas Health Innovation, Melbourne, Australia). Covidence is a web-based software program that allows multiple reviewers to screen records against inclusion and exclusion criteria. Covidence was used both for title and abstract, and full text screening. Three reviewers independently conducted the initial screening of the titles and abstracts in pairs (NBH and RJM, NBH and RPL). If any abstract did not meet the inclusion criteria, it was excluded. If reviewers could not determine whether the study should be included or excluded, the study was discussed, and a decision was made with 100% consensus among the three authors (NBH, RJM and RPL).

For full text screening, each of the potentially eligible studies was assessed and appraised by three reviewers in pairs (NBH and RJM, NBH and RPL). Any studies that did not meet the inclusion criteria were excluded. Disagreements were discussed and consensus reached.

Data extraction

For studies that met the inclusion criteria, the following data were extracted: (a) study characteristics (i.e. author and publication year, study objectives, study design, location, sample size, type of rehabilitation settings); (b) description of the intervention or new model of care; (c) implementation evaluation outcomes; and (d) facilitators or barriers to implementation. Data extraction was initially performed by one reviewer (NBH) and verified for accuracy by two reviewers (RJM, RPL). Any disagreement was discussed among the three review authors (NBH, RJM, RPL) and resolved by mutual consensus.

Quality assessment

The methodological quality of the included studies was independently assessed by one reviewer (NBH) and verified for accuracy by two reviewers (RJM, RPL) using the Mixed Methods Appraisal Tool (MMAT), version 2018 (Supplemental file 8).²³

The MMAT comprises two screening questions and five domains. Each domain pertains to a type of study design (i.e., qualitative studies, quantitative randomized controlled trials, quantitative non-randomized studies, quantitative descriptive studies, and mixed methods studies) and contains methodological quality criteria that are scored either yes, no, or cannot tell. An overall quality score ranging from zero to five stars can be derived based the proportion of criteria in a domain that are rated yes: 100% (5 stars), 80% (4 stars), 60% (3 stars), 40% (2 stars), 20% (1 stars), and 0% (0 stars).^23,24 For mixed methods studies, which are rated on three domains, the overall quality score is set as the lowest domain score.^23,24 Any disagreement was discussed among the reviewers and resolved by mutual consensus.

Data synthesis

The information extracted from the included studies was tabulated and narratively synthesised. The narrative synthesis involved reviewing the facilitators and barriers reported in the results and discussion sections of each study and categorising the factors using the CFIR. The classification was conducted by one reviewer (NBH) using an inductive, iterative process, where each characteristic was classified, and appraised by two reviewers (RJM, RPL). Each barrier or facilitator identified was then categorised to one domain in CFIR,²² and multiple factors could be identified for each study (Supplemental files 10 and 11).

Results

A total of 9044 records were identified during database searches. Of these, 885 records were duplicates and removed. After screening the titles and abstracts of the remaining 8159 records, 7961 records were excluded, and 198 potentially eligible studies were selected for full text screening. After full-text screening, 62 studies were included. Eleven articles were identified during backward citation searching and only two of those articles were included, resulting in 64 included studies (Figure 1).^{5–7,9–13,25–80}

Figure 1.

PRISMA flow chart.

Over half (59%) the included studies were conducted in Australia (n = 14), the United States (n = 13), United Kingdom (n = 7), the Netherlands (n = 7) or Canada (n = 8). The remaining studies were conducted in Ireland (n = 4), Norway (n = 2), and a single study each in Austria, Germany, China, India, France, Lithuania, Poland, and Switzerland. One study was conducted in collaboration across three countries: Australia, New Zealand, and Scotland (Table 1).

Table 1.

Characteristics of included studies.

Author/Year	Study objectives	Study design	Country	Study period	Study population
Abrahamson et al. 2017²⁵	To evaluate the feasibility and impact of implementing a care model for post-acute care residents within the skilled nursing facility	Mixed methods	United States	NR	Post-acute patients and family caregivers (n = 39), mean age 73.4 (SD NR) years
Ahmedzai et al. 2022⁹	To assess the feasibility and acceptability of a newly developed community-based multidimensional cancer rehabilitation program	Mixed methods	Norway	2011 to 2019	Local community members who have been diagnosed with any type of cancer (n = 55), mean age 55.7 (SD 9.5) years
Alber et al. 2017¹⁰	To determine whether combined transcranial direct current stimulation and vision restoration training can be effectively implemented in the early recovery phase following stroke, and to explore the feasibility, safety, and efficacy of an early intervention	Quantitative descriptive	Austria	2013	Hemianopia patients (n = 14), mean age 60.1 (SD 13.9) years
Antcliff et al. 2021²⁶	To test the feasibility of using the activity pacing framework to underpin a rehabilitation programme for chronic pain/fatigue	Quantitative non-randomised	United Kingdom	May 2018 to Dec 2019	Patients with history of chronic pain from a rehabilitation programme (n = 106), mean age 55.3 (SD 12.8) years
Aramaki et al. 2019²⁷	To analyse the feasibility of a rehabilitation protocol using client-centered virtual reality and to evaluate changes in occupational performance and social participation	Mixed methods	Brazil	Jan 2017 to Aug 2017	Subacute and chronic stroke patients (n = 10), mean age NR
Argent et al. 2018²⁸	To explore the opinions of orthopaedic healthcare professionals regarding the opportunities and challenges and perceived impact of a prototype wearable exercise biofeedback system	Qualitative	Ireland	2018	Orthopaedic department staff (n = 10), mean age 36.5 (SD 9.1) years
Barker et al. 2019²⁹	To identify perceived enablers and barriers that may influence the implementation of water protocols as an intervention for dysphagia in acute stroke settings	Qualitative	Australia	May 2017 to Jul 2017	Acute stroke unit staff (n = 26), mean age NR
Baxter et al. 2023³⁰	To investigate the feasibility of implementing a manual therapy technique, muscle energy technique protocol	Mixed methods	Australia	Feb 2018 to Dec 2019	COPD patients (n = 33), mean age 74 (SD NR) years
Bayley et al. 2012³¹	To describe the barriers to implementation of evidence-based recommendations for stroke rehabilitation	Qualitative	Canada	2003	Healthcare providers (n = 79), mean age NR
Benzo et al. 2018³²	To communicate the development and feasibility of a home- based pulmonary rehabilitation (PR) program that includes commercially available technology that allows the PR health coach to follow the patient through his or her PR process and to present the design of a prospective clinical trial	Qualitative	United States	NR	Chronic obstructive pulmonary disease (COPD) patients (n = 3 and n = 12 for first and second pilot studies, respectively), mean age NR
Bloemen- Vrencken et al. 2005³³	To describe the development, content, applicability, and implementation experiences of a transmural care model in the rehabilitation sector	Mixed methods	The Netherlands	NR	Transmural nurses and spinal cord injury patients who were discharged from clinical rehabilitation (n = 134), mean age 47.2 (SD 15.6) years
Brady et al. 2011³⁴	To develop and evaluate the implementation of a complex, multidimensional oral health care intervention for people in stroke rehabilitation settings	Mixed methods	Canada	NR	Stroke patients (n = 40), mean age 72 (SD 12.2) years; Nursing staff (n = 26), mean age NR
Bragstad et al. 2019³⁵	To evaluate to what extent a dialogue-based psychosocial intervention was delivered according to protocol	Mixed methods	Norway	Nov 2014 to Nov 2016	Stroke survivors with and without aphasia (n = 322), mean age 66.7 (SD 12.0) years
Brusco et al. 2019⁷⁵	To determine feasibility of increasing the dosage of inpatient occupational therapy and physiotherapy rehabilitation with independent tasks and exercises outside of supervised sessions, with a programme called ‘My therapy’.	Quantitative randomised	Australia	2019	Frail older hospital patients admitted to the rehabilitation programme as intervention (n = 116) and usual care group patients as control (n = 89), mean age 79 (SD 9.9) years
Brusco et al. 2023⁷⁶	To investigate barriers and facilitators to implementing self- directed therapy activities called ‘My therapy’; from the perspective of patients and clinicians in an adult inpatient rehabilitation.	Quantitative descriptive	Australia	2022	Physiotherapists, occupational therapists, and patients (n = 31; 11 patients and 20 clinicians), mean age: 70 (SD NR)
Calo et al. 2020³⁶	To assess the clinicians course implementation of the program in outpatient rehabilitation clinics	Qualitative	United States	Jun 2017 to Dec 2017	Clinicians (n = 96), mean age NR
Cerini et al. 2021³⁷	To evaluate the implementation of the home-based, minimal- equipment exercise training program from the perspectives of all involved persons and to optimize the program to ensure its long-term sustainability	Mixed methods	Switzerland	NR	Survey: COPD patients (n = 53), mean age 66.2 (SD 8.2) years; coaches (n = 12), mean age NR Interviews: COPD patients (n = 9), mean age NR; coaches (n = 7), mean age NR; relevant stakeholders (n = 6), mean age NR
Clark et al. 2014³⁸	To address the challenges confronted in implementing a pressure ulcer prevention study by assessing the efficacy of a complex, preventive intervention in reducing the incidence of, and costs associated with, the development of medically serious pressure ulcers in people with spinal cord injury	Mixed methods	United States	Feb 2009 to Nov 2011	Spinal cord injury patients (n = 170), mean age NR
Cochrane et al. 2016³⁹	To explore the views of stakeholders, including patients and the healthcare team, on the feasibility, acceptability and barriers to a collaborative, multidisciplinary team-based care intervention to improve health outcomes in COPD patients, within the context of a local hospital outpatient clinic	Mixed methods	Australia	Jun 2015	COPD patients (n = 12), mean age 64 (SD 11) years
Connell et al. 2014⁴¹	To conduct a formative evaluation of the implementation of the graded repetitive arm supplementary program to inform the development and implementation of a similar intervention in the United Kingdom	Qualitative	Canada	NR	Therapists (n = 20), mean age NR
Connell et al. 2018⁴⁰	To investigate factors influencing implementation of higher- intensity activity in stroke rehabilitation settings	Qualitative	Canada	Nov 2016 to Jan 2017	Rehabilitation therapists and rehabilitation assistants (n = 15), mean age 37 (SD 9.2) years
Currin et al. 2016⁴²	To investigate the processes required for the service change program model of care change within an existing allied health community rehabilitation service	Quantitative descriptive	Australia	NR	Senior staff and team managers (n = 9), mean age NR; Clients (n = 15), mean age NR
Daw et al. 2022^43,a	To assess and compare change in key outcomes before and after the supervised period of the rehabilitation enablement in chronic heart failure (REACH-HF) model across the multiple study sites to those of the intervention arm of the multicentre trial	Quantitative descriptive	United Kingdom	Jun 2019 to Jun 2020	Chronic heart failure patients (n = 132), mean age 75.6 (SD 11.1) years
Daw et al. 2022^44,a	(1) To identify barriers to, and facilitators of implementation of the rehabilitation enablement in chronic heart failure (REACH-HF) model using two different cohorts of healthcare professionals (2) To develop and refine an implementation manual to inform the future implementation of the REACH-HF programme	Mixed methods	United Kingdom	Mar 2019 to Apr 2021	Interviews: Healthcare professionals (n = 17), mean age NR; Survey: staff (n = 85), mean age NR
Dennett et al. 2021¹²	To determine the feasibility of implementing a flexible, exercise-based cancer rehabilitation program in a hospital- based cancer unit	Quantitative descriptive	Australia	Oct 2019 to Mar 2020	Cancer survivors (n = 73), mean age 63 (SD 11) years
Dow et al. 2010⁴⁵	To describe and evaluate the effectiveness of an innovative model of rehabilitation designed to meet the needs of a sparsely populated rural area	Quantitative descriptive	Australia	Jul 2004 to Jun 2006	Patients from acute care unit (n = 112), mean age 74.2 (SD 14.3) years
Eakin et al. 2015 (13)	To describe a multidisciplinary team perspective regarding how to implement and sustain a successful early rehabilitation program	Qualitative	United States	Jan 2013 to Mar 2013	Staff and faculty who were involved in the early rehabilitation program (n = 20), mean age NR
Everink et al. 2017⁴⁶	To assess the feasibility of the integrated care pathway in geriatric rehabilitation using a process evaluation	Mixed methods	The Netherlands	Apr 2013 to Aug 2014	Geriatric patients (n = 113), mean age 81 (SD 6.9) years; informal caregivers (n = 37), mean age 63 (SD 15.4) years; healthcare professionals (n = 19), mean age NR
Fazio et al. 2020⁴⁷	To describe the process of developing and implementing a functional electrical stimulation leg cycle ergometry program for spinal cord injury (SCI) patients within acute rehabilitation	Quantitative descriptive	United States	2016 to 2018	People with chronic SCI or their family or caregiver (n = 220), mean age NR
Feldman et al. 2022⁴⁸	To assess the feasibility of the stroke home health aide recovery program and to pilot research procedures in anticipation of a full-scale randomized controlled effectiveness trial	Mixed methods	United States	Jun 2018 to Aug 2019	Patients with ischemic or haemorrhagic stroke history (n = 60), mean age 65.6 (SD 13.2) years
Hopkinson et al. 2012⁴⁹	To design and evaluate implementation of a COPD discharge care bundle	Mixed methods	England	Oct 2009 to Sep 2010	COPD patients on the respiratory ward (n = 94), mean age 74.6 (SD 11.2) years
Horne et al. 2015⁵⁰	To gain an in-depth understaffing of staff’s experience and views on delivering a complex rehabilitation intervention: Patient-led therapy during inpatient stroke care	Qualitative	England	NR	Stroke service staff (n = 13), mean age NR
Hreha et al. 2020^51,b	To implement the Kessler foundation neglect assessment process (KF-NAP) and the Kessler foundation prism adaptation treatment (KF-PAT), in an acute care hospital to determine their feasibility and sustainability	Quantitative descriptive	United States	NR	Patients with a history of right brain stroke survivors (n = 126), mean age 71 (SD NR) years
Hreha et al. 2022^52,b	To implement two evidence-based protocols and share the implementation process, which included barriers and facilitators identified during and after the process, and implementation outcomes	Mixed methods	United States	Jun 2017 to Mar 2021	Implementation champions (n = 32), mean age NR
Jolly et al. 2007⁵³	To evaluate the relative effectiveness and cost-effectiveness and, reasons for non-adherence of a home-based cardiac rehabilitation, the Birmingham rehabilitation uptake maximisation study, using the heart manual, compared with centre-based programmes	Mixed methods	England	2002 to 2004	Patients who had experienced a myocardial infarction or coronary revascularisation (n = 525), mean age 60.3 (SD 10.5) years for home-based group and 61.8 (SD 11.0) years for centre-based group
Kania et al. 2023⁷⁷	To identify factors impacting the implementation of the good life with osteoarthritis: Denmark (GLAD) program in both publicly funded and private rehabilitation settings, based on the experience of the initial cohort of providers and clinic leaders who set up and delivered the program.	Qualitative	Canada	May 2016 to Sep 2017	Trained healthcare providers and three clinic leaders from a range of clinical settings (n = 18), mean age and SD NR
Kennedy et al. 2012⁵⁴	To explore the design, implementation, utility, and acceptability of the new model using clinicians’ perceptions and experiences through an evaluation	Qualitative	Australia	May 2011 to Sep 2011	Staff (n = 15) and stakeholders (n = 3), mean age NR
Lamper et al. 2022¹¹	To provide insight into barriers and facilitators for the development, implementation, and transferability of the transmural network pain rehabilitation Limburg model for chronic musculoskeletal pain patients	Qualitative	The Netherlands	Oct 2017 to Oct 2018	Health care professionals (n = 21), mean age NR; patients (n = 58), mean age NR; stakeholders (n = 3), mean age NR
Li et al. 2019⁵⁵	To report the feasibility and preliminary effects of a psychosocial care program entitled‚ a coping oriented supportive program for people with spinal cord injury (SCI) during inpatient rehabilitation	Mixed methods	China	Mar 2016	People with SCI (n = 20), mean age 41.7 (SD 8.1) years for intervention group and 43 (SD 15.7) years for control group
Liu et al. 2019⁵⁶	To better understand trial outcomes through assessing trial implementation and exploring patients‚ carers and providers perspectives	Mixed methods	India	NR	Stroke patients (n = 22), carers (n = 22) and health providers (n = 28), mean age 57.7 (SD NR) years
Logan et al. 2022⁵⁷	To determine the feasibility of conducting a randomised controlled trial of a functional standing frame programme compared with usual physiotherapy for people with severe sub-acute stroke	Mixed methods	England	Jan 2017 to Sep 2017	Stroke patients (n = 45), mean age 81.7 (SD 11.7) years for intervention group and 78.9 (SD 10.5) years for control group
Luker et al. 2016⁵⁸	To better understand how the implementation of a rehabilitation intervention in a clinical trial within acute stroke units is experienced by the staff involved	Qualitative	Australia, New Zealand, and Scotland	2006 to 2014	Stroke patients (n = 53), mean age NR
Lutz et al. 2020⁵⁹	To identify successes and challenges of the comprehensive post-acute stroke services for transitional care model with integration into the clinical workflow	Qualitative	United States	2016 to 2018	Stroke patients (n = 2,689), mean age NR; hospital frontline clinicians and administrators (n = 19), mean age NR; director of implementation (n = 2), mean age NR
Luu et al. 2022⁶⁰	To assess the impact of the (programme d’accompagnement de retour a' domicile) PRADO programme on enrolled stays in orthopaedic surgery over the last 3 years	Mixed methods	France	Jan 2015 to Dec 2017	Orthopaedic surgery patients (n = 71,761), mean age 63.3 (SD 14.1) years for intervention group and 63.1 (SD 14.4) years for control group
Manhas et al. 2021⁶¹	To explore experiences of early-adopter providers and provincial consultants involved in the community- rehabilitation model of care implementation	Qualitative	Canada	Apr 2017 to Nov 2018	Rehabilitation professionals (n = 45), mean age 41.4 (SD 11.6) years
Misra et al. 2023⁷⁸	To assess the feasibility and effectiveness of a 12-week asynchronous remotely supervised exercise and patient education program, modeled on cardiac rehabilitation programs.	Quantitative non-randomised	United States	NR	Patients with atrial fibrillation (n = 12), mean age 67.5 (SD 79) years
Murphy et al. 2018⁵	To increase the implementation of sexual counselling guidelines in hospital-based cardiac rehabilitation	Mixed method	Ireland	Jun 2016 to Mar 2017	People living with cardiovascular disease and their partners and staffs (n = 42), mean age 51.3 (SD 4.7) years for Dublin centre staff, 46.7 (SD 9.6) years for non-Dublin centre staff, 58.9 (SD 9.8) years for Dublin centre patients, and 62.3 (SD 13.2) years for non-Dublin centre patients
Murphy et al. 2019⁶³	To evaluate improvements of key performance indicators in hip fracture care after implementation of a formal orthogeriatric service	Quantitative descriptive	Ireland	Aug 2017 to Feb 2019	Older patients after hip fracture (n = 146 and n = 139 at time points 1 and 2, respectively), mean age 81.8 (SD NR) years at time point 1 and 79.6 (SD NR) years at time point 2
Marsden et al. 2023⁶²	To determine if our practice-change package implementation stroke continence assessment and management plan is effective and feasible for improving then maintaining urinary continence care in wards that admit acute and rehabilitation patients with various diagnoses in Australian metropolitan and regional hospitals	Quantitative non-randomised	Australia	Dec 2018 to Feb 2022	Patient with urinary continence symptoms (n = 780), mean age 78 (SD NR) years at T0, 76 (SD NR) years at T1, and 76 (SD NR) years at T2
Paleviciute et al. 2021⁶	To share the experience of implementing a pulmonary hypertension rehabilitation program, to summarise the barriers and prerequisites for launching this service, and to assess its early effect	Quantitative descriptive	Lithuania	Feb 2017 to Feb 2019	Pulmonary hypertension patients (n = 9), mean age NR
Parry et al. 2017⁶⁴	To identify factors (barriers and enablers) that influence clinicians’ implementation of early rehabilitation in the intensive care unit (ICU) setting across 2 tertiary hospitals	Qualitative	Australia	2014 to 2015	Clinicians working in ICU (n = 26), mean age 28 (SD NR) years
Room et al. 2023⁷⁹	To examine the acceptability and feasibility of an exercise adherence intervention (AERO) in facilitating exercise adherence in older people with musculoskeletal conditions, and to inform the design of a future randomised controlled trial.	Mixed methods	England	NR	People with musculoskeletal conditions (n = 48; 27 randomised to usual care and 21 to AERO and usual care), mean age 76 (SD 8.5) years
Sadural et al. 2022⁶⁵	To describe the development and evaluation of a proactive, consultative occupational therapy program for people with early Parkinson disease as a part of an integrated care approach	Mixed methods	United States	2017 to 2018	People with early Parkinson disease (n = 71), mean age 44 (SD NR) years
Scheffers- Barnhoorn et al. 2021⁶⁶	To gain insight into factors related to the intervention process that may have influenced the effectiveness of the intervention	Mixed methods	The Netherlands	Mar 2016 to Jan 2017	Hip fracture patients from geriatric rehabilitation units (n = 39), mean age 83.7 (SD 7.3) years; physiotherapists (n = 14), mean age NR; psychologists (n = 6), mean age NR
Scovil et al. 2014⁶⁷	To implement pressure ulcer prevention best practices in spinal cord injury (SCI) rehabilitation using implementation science frameworks	Quantitative descriptive	Canada	Jan 2012 to Jul 2013	SCI patients and hospital staff (n = 35), mean age NR
Stout et al. 2023⁶⁸	To provide a roadmap to facilitate implementation of cancer rehabilitation navigation in cancer care delivery model	Qualitative	United States	2019	Stakeholders including physicians, administrators, clinical staff, and patients (n = 15), mean age NR
Talbot et al. 2014⁷	To describe the implementation of a clinical management model and to provide a perception of the quality of care and services provided to patients with moderate or severe traumatic brain injury and to their caregivers	Qualitative	Canada	2010 to 2011	Patients with a traumatic brain injury (n = 11), mean age 40.7 (SD 18) years; caregivers (n = 9), mean age 50.7 (SD NR) years; hospital administrators (n = 6), mean age NR; clinicians (n = 14), mean age NR
Tielemans et al. 2016⁶⁹	(1) To investigate whether the self-management intervention was implemented as intended (2) To observe involvement in and satisfaction with the intervention among patients, their partners, and therapists	Mixed methods	The Netherlands	Feb 2013 to May 2014	Stroke patients (n = 53), mean age 55.5 (SD 9.1) years; patient’s partners (n = 28), mean age 57.2 (SD 7.9) years; therapists (n = 19), mean age NR
Varnfield et al. 2014⁷⁰	To investigate the effect of a smartphone-based home service delivery of care assessment platform (CAP-CR) on cardiac rehabilitation use and health outcomes compared with a traditional, centre-based rehabilitation programme (TCR), in post-myocardial infraction patients	Quantitative randomised controlled trial	Australia	May 2009 to Feb 2011	Post-myocardial infraction patients (n = 120), mean age 55 (SD 48) years for CAP-CR group and 57 (SD 34) years for TCR group
Wageck et al. 2020⁷¹	To address barriers to uptake and completion of pulmonary rehabilitation following an acute exacerbation of COPD	Mixed methods	Australia	NR	Phase 1: COPD patients who were admitted and discharged from the respiratory or general medicine wards (n = 10), mean age 75 (SD 8) years Phase 2: Admitted COPD patients (n = 14), mean age NR; clinicians (n = 12), mean age NR Phase 3: Admitted COPD patients (n = 5), mean age 68 (SD 15) years
Weerakkody et al. 2023⁷²	To describe the steps and processes undertaken in developing and implementing a behaviour change intervention model for movement therapy to increase the delivery of in a large multi-site, early supported discharge, community-based, rehabilitation service	Quantitative descriptive	Australia	Oct 2018 to Nov 2019	Neurological expert clinicians including physiotherapist and occupational therapists (n = 35), mean age NR
Wielaert et al. 2018⁷³	To address the introduction of a novel conversation partner training programme which targets partners of persons with aphasia as recipients of training in rehabilitation practice on a multicentre scale	Mixed methods	The Netherlands	NR	Professionals from the implementation of Aphasic Clients conversation training team, the rehabilitation centres and the knowledge brokers (n = 20), age NR
Wojciuk et al. 2021⁷⁴	To assess the effectiveness and safety of a 6-month home- based caregiver-supervised rehabilitation program among patients with pulmonary arterial hypertension	Quantitative randomised controlled trial	Poland	Mar 2019 to Jul 2020	Patients with pulmonary arterial hypertension (n = 39), mean age 48.9 (SD 18.3) years for intervention group and 53.7 (SD 12.8) for control group
Wolf et at. 2023⁸⁰	To evaluate the feasibility of implementing multimodal agility- based exercise training (MAT) in an inpatient rehabilitation setting and the feasibility of a randomized controlled trial study protocol with ‘traditional’ strength and endurance training (SET) as an active control condition.	Mixed methods	Germany	2021-2022	Persons with multiple sclerosis with a potential to impact fatigue and fatigability (n = 22; the intervention period lasted from admission (T0) to discharge (T1); intervention group MAT, n = 11, Sat, n = 11; T1 discharge phase and T2 post rehab follow ups in home phase), mean age 45.6 (SD: MAT 10.1 and SAT 9.3)

AERO: an exercise adherence intervention; CR: cardiac rehabilitation; COPD: chronic obstructive pulmonary diseases; CAP-CR: care assessment platform on cardiac rehabilitation; GLAD: the good life with osteoarthritis: Denmark; ICU: intensive care unit; MAT: multimodal agility-based exercise training; N/A: not applicable; KF-NAP: Kessler Foundation neglect assessment process; KF-PAT: Kessler Foundation prism adaptation treatment; NR: not reported; PR: pulmonary rehabilitation; PRADO: programme d’accompagnement de retour a' domicile; REACH-HF: rehabilitation enablement in chronic heart failure; SD: standard deviation; SCI: spinal cord injury; SAT: strength and endurance training; TCR: traditional, centre-based rehabilitation.

^aReporting on the implementation of the same intervention or model of care (i.e. REACH-HF).

^bReporting on the implementation of the same intervention or model of care (i.e. KF-NAP and KF-PAT).

Twenty-seven (43%) studies employed mixed methods, 20 (32%) used qualitative methods, and the remaining 16 (25%) studies used quantitative methods. Most studies were hospital-based (81%, n = 52) and the remaining studies (19%, n = 12) were home, community-based, or involved mixed rehabilitation settings.

The mean age of participants across the sample ranged from 28.0 to 83.4 years. More than three-quarters of included studies (78%, n = 50) focused on new rehabilitation care models for chronic diseases and conditions including stroke, aphasia, atrial fibrillation, cancer, chronic obstructive pulmonary disease, chronic pain, frailty, musculoskeletal pain, Parkinson’s disease, and pulmonary hypertension. Eleven contributions (19%) assessed new models of care for injuries including spinal cord injury, hip fracture, or brain injury. Two studies (3%) examined rehabilitation models specifically for rural populations, and one examined the implementation of early rehabilitation in an intensive care unit.

Over two-thirds of the included studies (63%, n = 40) reported implementation evaluation metrics, including fidelity (n = 15), adherence (n = 16), feasibility (n = 14), acceptability (n = 12), reach (n = 7), implementation cost (n = 5), sustainability (n = 4), and adoption (n = 3). Appropriateness was reported in one study (Table 2).

Table 2.

Implementation evaluation outcomes in included studies by evaluation domain.

Author/Year	Implementation evaluation outcome	Adoption	Acceptability	Appropriateness	Feasibility	Fidelity	Implementation cost	Reach	Sustainability
Ahmedzai et al. 2022⁹	(1) Inconsistencies in intervention delivery due to staff turnover.				✓
	(2) Inconsistencies for sessions due to staff unavailability.				✓
	(3) Modifications needed in physical exercise due to various participant fitness levels.				✓
	(4) High adherence from participants with a mean of 76% of the 24 exercise sessions and 83% of the 7 psychoeducation sessions.		✓			✓
	(5) The program content and structure were well received.		✓			✓
Alber et al. 2017¹⁰	(1) All patients received the treatment protocol.				✓			✓
Antcliff et al. 2021²⁶	(1) The recruitment rate (77%) was high and 100% of participants attended at least one session.				✓			✓
	(2) High satisfaction reported by patients.		✓
	(3) Treatment adherence for patients was 56.1%, with dropout common after 1 week due to unrealistic expectations.					✓
	(4) Healthcare professionals reported 100% adherence in their fidelity checklists for rehabilitation components.					✓
Aramaki et al. 2019²⁷	(1) 100% adherence as all patients completed the 36 sessions of the intervention.				✓	✓
Baxter et al. 202330	(1) The median number of attendance rates to pulmonary rehabilitation (PR) were 13 out of the 16 sessions (81%).					✓
Baxter et al. 202330	(2) Twenty-seven of the participants (81%) participated in the week 12 telephone call. All 27 respondents (100%) expressed that they enjoyed the muscle energy technique component of the study.			✓
Benzo et al. 2018³²	(1) Pilot Study 1: Overall study adherence was 87%.					✓
Benzo et al. 2018³²	(2) Pilot Study 2: Overall study adherence was 87%. The response rate was 100%. Majority of the participants felt that the program was suited to their needs and interests.				✓	✓
Brady et al. 2011³⁴	(1) Model implementation was viewed as feasible and facilitated the delivery.				✓
	(2) Patients’ views: some patients found it difficult to recall and conduct the oral health care intervention. Some participants believed that the intervention was not a priority for staff who were perceived to be more focused on clinical signs.				✓
	(3) Staffs view: Less than half of the patients reported they were registered with a dentist (n = 16; 40%) and around a quarter (n = 11; 28%) were able to provide their dentist’s name or other contact details.				✓
Bragstad et al. 2019³⁵	(1) Participants completed, on average, 7.4 sessions of the maximum 8 sessions. In total, 140 participants (90.9%) received a complete intervention program of 6 sessions.					✓
Bragstad et al. 2019³⁵	(2) Based on the number of delivered sessions alone, 90.9% of the interventions were implemented with high fidelity. Based on the composite score, 80.1% of the interventions were implemented with high fidelity, e.g. Prolonged time without practical experience with delivering the content of the intervention hampered the fidelity.					✓
Brusco et al. 2019⁷⁵	(1) Participation in intervention group was achieved by 72% (83/116) who averaged 14 min of daily practice outside of usual; supervised sessions. The intervention was considered as safe and feasible.				✓	✓
Calo et al. 2020³⁶	(1) An average of 13 patients (range 1-60) per clinic received the program.							✓
	(2) Over three-quarters of respondents implemented the model in outpatient rehabilitation clinics and among those, 93% were still delivering it.	✓							✓
	(3) High levels of implementation fidelity with all core program components being implemented by over two thirds of respondents. Four out of the 8 components were implemented by 90% or more of respondents.					✓
Cerini et al. 2021³⁷	(1) All the 53 participants received exercise equipment for home use.							✓
	(2) All materials were provided according to protocol.					✓
	(3) On average, the 52 intervention group participants were adherent for 37.8 weeks (72.6%).					✓
	(4) Patients’ exercises were adaptable to their current health state.			✓	✓
	(5) Stakeholders found the model highly acceptable and adaptable in terms of volume and intensity.			✓	✓
Cochrane et al. 2016³⁹	(1) The implementation of a collaborative team-based chronic obstructive pulmonary disease management intervention trialled in this pilot project was not feasible in its current form.				✓
Connell et al. 2014⁴¹	(1) All components of the model, when implemented in practice, were adapted to some extent to fit with therapists’ concerns about self-directed exercise and their working context.					✓
Currin et al. 2016⁴²	(1) An audit was undertaken of a random selection of 15 client charts and 65% were provided a lifestyle modification.								✓
Currin et al. 2016⁴²	(2) Staff documentation of the international classification of functioning, disability, and health framework was at a high level across all time points, as was evidence of team interactions.								✓
Daw et al. 2022⁴³	(1) Out of 132 patients, 96 (72.7%) completed the programme.					✓
Dennett et al. 2021¹²	(1) All participants reported satisfaction with the program. On average, participants attended 7 of 16 available sessions. Participants who opted for twice weekly exercise attended 9/16 sessions (56%), and once weekly attended 3/8 sessions (40%).		✓
Dennett et al. 2021¹²	(2) The average health service cost per participant was AUD $1,104						✓
Everink et al. 2017⁴⁶	(1) The discharge nurses used the triage instrument for 100% of the patients.					✓
	(2) Nurses and patients were involved in the triage decision, establishing patient care, the treatment plan and rehabilitation goals.					✓
	(3) Healthcare professionals from the hospital and the geriatric rehabilitation facility expressed their satisfaction with the triage instrument.					✓
Fazio et al. 2020⁴⁷	(1) Training was provided for staff and incorporated care model sessions into clinical practice.				✓
Fazio et al. 2020⁴⁷	(2) Evening community fitness program provided an opportunity for former patients to use equipment with assistance from a therapy technician. This change led to a large increase in model use.				✓
Feldman et al. 2022⁴⁸	(1) Coaches were satisfied with their training, but felt they needed additional one on one contact with study staff.		✓
	(2) Training met trainees needs 98% of the time.		✓
	(3) Positive attitudes and direct involvement of rehabilitation supervisors, training staff, and frontline aides.					✓
	(4) Coaches and participants met the 100% threshold for setting at least 1 mobility exercise goal. The study failed to meet either the 80% threshold for joint coach visits or the 85% threshold for joint coach/physical therapist visits.					✓
Hreha et al. 2020⁵¹	(1) No refusals or withdrawals from patients or adverse events occurred at any time during the study.				✓
	(2) The fidelity of both protocols‚ key components were maintained.				✓
	(3) Due to the acute care environment and patients’ complexity, protocol adaptation did occur.	✓
	(4) Challenges occurred due to the short length of acute care stay and scheduling difficulties.					✓
	(5) The therapists were able to maintain using the protocols.								✓
Jolly et al. 2007⁵³	(1) The mean costs for the home-based programme were £198 versus £157 for the centre-based programme.						✓
Kania et al. 2023⁷⁷	(1) The program ranged from $350‐$475 CDN (Canadian currency).						✓
	(2) Program acceptability was very well received by the healthcare providers.							✓
	(3) Average intervention fidelity ratings were between 5.6 and 7 (maximum 7) for the eight group sessions.					✓
	(4) All the participants scored the trial as appropriate or very appropriate.		✓
Li et al. 2019⁵⁵	(1) The recruitment rate was 88%.					✓
	(2) The retention rate was 100%. A total of nine (82%) of the 11 participants in the intervention group completed five or more intervention sessions.					✓
	(3) Average intervention fidelity ratings were between 5.6 and 7 (maximum 7) for the eight group sessions.		✓
	(4) All the participants scored the trial as appropriate or very appropriate.								✓
Liu et al. 2019⁵⁶	(1) Trial components of goal setting, gait training, and functional mobility were implemented as intended.					✓
	(2) Early supported discharge was not achieved due to lack of hospital beds.					✓
	(3) Favourable comments from stroke coordinators.		✓
	(4) The model was sustainable for those with limited access to rehabilitation.							✓
Logan et al. 2022⁵⁷	(1) The mean number of sessions was 8.0 (SD 4.7) for the intervention group and 11 (SD 4.5) in the usual physiotherapy group.					✓
	(2) One site stopped recruiting after 2 months due to significant staffing issues.					✓
	(3) 91% of sessions were reported as enjoyed by participants.		✓
Lutz et al. 2020⁵⁹	(1) Difficulties with eligibility determination happened most often with patients with a transient ischemic attack or mild stroke.							✓
Lutz et al. 2020⁵⁹	(2) Integrating the care model into existing programs threatened fidelity.					✓
Luu et al. 2022⁶⁰	(1) Mean expenditures at 6 months were lower in the intervention compared to the control group (I: € 2248 vs. C: € 2485)						✓
Misra et al. 2023⁷⁸	(1) In total, 92% (11/12) of participants completed the 12-week program through the exit visit. Over the course of the 12-week program, 94% of expected patient contacts between the exercise physiologist and the participant were made, with a total of 136 patient contacts of an expected 144 contacts. For the requested daily recording of blood pressure and ECG, this frequency is associated with a 48% adherence rate and an 81% adherence rate, respectively.					✓
Misra et al. 2023⁷⁸	(2) Participants strongly agreed that they would be able to apply the education they received to future decisions about their health, and they would recommend this program to other patients (9/10 and 8.215/10, respectively)		✓						✓
Manhas et al. 2021⁶¹	(1) Lack of sufficient coverage for clinical responsibilities to complete implementation tasks.					✓
Manhas et al. 2021⁶¹	(2) Challenges to sustainability include competing responsibilities, lack of clarity or connection to the new model vision, less traditional clinical settings, and team dynamics.								✓
Murphy et al. 2018⁵	(1) Adherence interventions were on average 69% for both centres.					✓
	(2) All elements of the patient education session were delivered as intended.					✓
	(3) Some staffs had reservations about the sexual nature of the intervention.		✓
	(4) Patient perceptions of the intervention were highly positive.		✓
	(5) Estimated delivery of the intervention for staff costs was €26.25 per group.						✓
Murphy et al. 2019⁶³	(1) Increase from 31.2% to 96.5% in the proportion of patients seen by a geriatrician, and an increase from 7.4% to 98.5% in patients who had a formal falls assessment.					✓
Marsden et al. 2023⁶²	(1) All 13 wards adopted the practice change package.					✓
Paleviciute et al. 2021⁶	(1) All patients were satisfied with the program and reported that they continued training at home daily for about 9–12 months.				✓
Room et al. 2023⁷⁹	(1) Acceptability was explored in the qualitative interviews with patient participants and physiotherapy participants. The intervention considered by the participants as feasible and acceptable.		✓		✓
	(2) At least one adherence strategy was used with all 10 participants, and all had exercises recorded in their exercise diary. Fidelity was therefore categorised as excellent.					✓
	(3) Participant retention was good with only one complete dataset missing at 6 weeks and 12 weeks. On the whole, missing data was low, with a completion rate of at least 93%, except for exercise diaries that had a completion rate of 77% due to missed entries or loss of the diary.								✓
	(4) Adherence percentage of exercise completed was 63% (SD 27) and 77% (SD 18) for the usual care and the intervention group respectively.					✓
Sadural et al. 2022⁶⁵	(1) In 2018, program reach grew from 30% to 47% in 2022.							✓
	(2) Over time, adoption spread to 2 sites, 4 occupational therapists, and 11 referrers.	✓
	(3) The program was sustained for the duration of 2018 and 2022 with adaptations including new organisational leadership support and mentorship opportunities.					✓
Scheffers-Barnhoorn et al. 2021⁶⁶	(1) The frequency of coaching of physiotherapists by psychologists decreased over time.:							✓
	(2) Participation during the intervention was very good to excellent (56%) for most patients (n = 20).					✓
	(3) To a fair degree the intervention was performed according to protocol, but cognitive restructuring and the telephonic booster were not provided to all patients.				✓
Tielemans et al. 2016⁶⁹	(1) 62% patients and 60% partners took part in all seven intervention sessions.					✓
	(2) In 20% of sessions, the action plan tool was inadequately used.				✓
	(3) 47% patients and 52% partners worked on their goals.				✓
	(4) No group was assessed below acceptable levels of satisfaction.				✓
	(5) 90% patients, all 25 partners and 19 therapists considered the intervention to be useful.				✓
	(6) All therapists reported satisfaction with the number of training sessions (84%) and frequency (58%) of the intervention.					✓
Varnfield et al. 2014⁷⁰	(1) 89% of CAP-CR participants adhered to daily exercise.					✓
Varnfield et al. 2014⁷⁰	(2) >85% of participants found the step counter to be motivational in reaching model goals.				✓
Wageck et al. 2020⁷¹	(1) Participants were satisfied with the structure and content of the home-based pulmonary rehabilitation program.				✓
Wojciuk et al. 2021⁷⁴	(1) Adherence to the recommended exercise protocol was on average 91.9 ± 14.1%.					✓
Wolf et at. 2023⁸⁰	(1) From end-of-treatment to 3 months follow-up was acceptable in both groups (78– 89%).					✓
	(2) A total of 122 gym-based and 76 pool-based MAT-sessions were logged and analysed for MAT-components. In SET, strength sessions included an average 2.8 exercises and participants performed an average 99.5% of the prescribed load.				✓
	(3) High adherence at least 18 therapy sessions completed during the stay per group + MAT: 22.7 (12–33) + SET: 30.8 (18–38). One exception was the pool session (only 76% adherence).				✓
	(4) Interviews statements indicated that the interventions and study processes were acceptable.				✓

CAP-CR: care assessment platform on cardiac rehabilitation; MAT: multimodal agility-based exercise training; PR: pulmonary rehabilitation; SAT: strength and endurance training; SD: standard deviation.

Facilitators and barriers

A total of 501 facilitators and barriers to the implementation of new models of care in rehabilitation were reported in five domains across 56 constructs of the CFIR (Figures 2 and 3; and Supplemental files, 10, 11 and 12).

Figure 2.

Facilitators to implementing new models of care in rehabilitation by CFIR domain

Figure 3.

Barriers to implementing new models of care in rehabilitation by CFIR domain

Innovation source domain

Fifty-seven factors were reported across eight constructs in the innovative source domain. Of these, three constructs (innovation source, innovation evidence-base, innovation relative advantage) were reported as facilitators and one construct (i.e. innovation complexity) was reported as a barrier. Four constructs (innovation adaptability, innovation trialability, innovation design, innovation cost) were reported as both barriers and facilitators. Factors related to user-friendly online health applications (e.g., “the eHealth application was user-friendly … stimulated them to adhere to the treatment” [p8]),¹¹ easy to learn and individually adaptable care models, simple and easy referral processes (e.g., “having the navigator in the physical space … facilitate[d] near-real-time engagement with patients” [p4]),⁶⁸ flexible scheduling and prioritising the convenience of participants (e.g., “we restricted our timeframe … cut it short … for the patients” [p7])⁵⁸ were cited as facilitators. Barriers included complex and inappropriate models (e.g., “model was not suitable for cognitive patients such as memory, concentration, problem-solving and initiation difficulties and neglect” [p9]),⁵⁰ time consuming rehabilitation sessions, and overlapping care models with existing rehabilitation interventions.⁶⁹

Outer setting domain

Seventy-four factors were reported across seven constructs for the outer setting domain. Of these, five constructs (critical incidents, policies and laws, financing, external pressure, performance measurement pressure) were reported as barriers. Two constructs (local attitudes, local conditions) were reported as both barriers and facilitators. Factors related to a positive attitude and enthusiasm of health professionals, the organisation of care delivery (e.g., “it’s very well laid out (therapist)” [p4],⁴¹ “very helpful, very visual (patient)” [p7]),³² healthcare provider job satisfaction, continuous staff training, feedback and monitoring regarding the implementation of the intervention were cited as facilitators. Barriers included negative attitudes and stigmatisation among staff and hospital management towards the intervention (e.g., “it has a large impact on our timetables (hospital management)”[p8],⁶⁹ “I actually found it had a negative impact on patients (staff)” [p6]),⁵⁰ negative responses from patients (e.g., perceptions that the intervention was not suitable for them), organisation policies and performance pressure (e.g., “therapists were under pressure to … make time to supervise the new intervention” [p5]),⁵⁰ and personal reasons for patient drop out from rehabilitation, such as sudden illness, lack of interest in continuing or being preoccupied with work.

Inner setting domain

One hundred and ninety-four factors were reported across 18 constructs for the inner setting domain. Of these, one construct (recipient-centeredness, for example, “a lot of patients have reported… they are doing it at the same time every day” (therapist))[p8] ⁵⁰ was reported as facilitator and five constructs (information technology infrastructure, deliverer-centeredness, tension for change, compatibility, access to knowledge and information, e.g., “I worry that it (the intervention) won’t give you all the information (therapist)) [p7] ²⁸ were reported as barriers. Eleven constructs (physical infrastructure, work infrastructure (e.g., “trying to contact the doctors and get them in position… is quite difficult……really busy unit”) [p6]²⁹, relational connections, communications, culture, relative priority, incentive system, mission alignment, available resources (e.g., “we have lot of issues of lack of resources….there is nobody that can consistently be doing this except me” (clinician) [p5]⁵⁹, funding, space, materials, and equipment (e.g. ,“ the availability of the equipment affects how much you can do with your patients” ))[p5] ⁴⁰ were reported both as barriers and facilitators. Factors related to organisational support from higher management, using an interdisciplinary work approach to implementation, teamwork and effective communication (e.g., “I’ve had couple of patients… I don’t have the time to keep calling them”) [p4],⁵⁹ adequate funding for implementation, available resources, organisational measures (such as celebrating recruitment milestones by building a shared sense of community) were cited as facilitators. Barriers included inadequate equipment, high staff turnover and cutbacks, lack of staff access to information, problems with the internet or information technology (IT) system (e.g., slow and complex verification processes, inadequate IT systems to identify and track patients), lack of user ability and confidence among staff and patients with the technology, lack of onsite skilled professional support and training for staff, lack of a rehabilitation culture, lack of communication with general practitioners on site, and limited funding to support implementation.

Individual domain

Forty-eight factors were reported across 12 constructs in the individual domain. Of these, two constructs (implementation facilitators, implementation leads) were reported as facilitators and three constructs (opinion leaders, innovation recipients, need) were reported as barriers. Seven constructs (high-level leaders, implementation team members, other implementation support, innovation deliverers, capacity, opportunity, motivation) were reported both as barriers and facilitators. Factors related to prior expertise and knowledge of the implementation team, availability of local champions (e.g., “an implementation team of stakeholder champions … was a critical factor in facilitating implementation” [p5]),⁶⁸ and additional supports for patients (such as peer or family support) were cited as facilitators in the individual domain. Barriers included lack of expertise and knowledge about the delivery of the intervention by staff (e.g., “we’re just not always sure how to do it (therapist)”) [p3]⁴⁰ and lack of motivation towards the intervention from higher management, and staff.

Implementation process domain

Forty-one factors were reported across eleven constructs for the implementation process domain. Of these, three constructs (teaming, reflecting and evaluating, innovation) were considered as facilitators. Eight constructs (assessing context, assessing needs, tailoring strategies, engaging, innovation deliverers, doing, implementation, adapting) were reported both as barriers and facilitators for the implementation process domain. Factors related to tailored interventions according to patient’s health condition (e.g., “for patients prone to fatigue … teams planned their day, timetabling harder and lighter activities and rests across the day”), [p7]⁵⁸ implementation planning before delivery to engage more patients (e.g., “participants enjoyed, felt relaxed as the researcher made them feel comfortable and explained the treatments clearly”) [p9]³⁰ and staff buy-in were cited as facilitators in this domain. Barriers included variation in patient fitness level and illness, patients’ different preferences for practicing the rehabilitation sessions, and inconsistencies in physiotherapists expectations with patients’ abilities.

Quality assessment

Almost half of the included studies (n = 28; 48%) received an overall quality rating of 5 stars. Of the remaining studies, 18 studies (31%) were classified as 4 stars, six studies (11%) as 3 stars, four studies (7%) as 2 stars, and two studies (3%) as 1 star (Supplemental file 9).

Discussion

This review identified factors that were reported to have an impact on the implementation of new models of care for patients across rehabilitation settings and characterised these factors as barriers or facilitators using the CFIR. Common facilitators for successful implementation of new care models for rehabilitation were uncomplicated models, positive staff attitudes, support and motivation from peers and the organisation, teamwork, resources for implementation, staff prior knowledge and skill, and planning according to need and context before implementation of the model. Common barriers to the implementation of new care models for rehabilitation were complex models, negative staff attitudes, communication gaps, staff turnover, lack of a rehabilitation culture, lack of staff motivation, issues with IT, lack of staff training, limited funding, no implementation champions, and lack of implementation planning for model delivery.

Ideally, a care model should be simple to comprehend for both those implementing it and the people receiving the care. In the studies included in this review, simple, user-friendly, and individually adaptable care models worked as facilitators,^{28,44,56,58,68,70} while complex models worked as barriers.^{9,31,41,50,55,58,66,67,72,77} Models with flexible scheduling, that were affordable and had modifiable training sessions were commonly reported to be user-friendly and successful in terms of implementation acceptance, adherence, practicality, and fidelity.^{26,27,32,40,41,75,78–80} This demonstrates the importance of designing a care model with detailed and clear implementation steps for care providers that are also acceptable for participants.

Readiness to accept change can be influenced by organisational culture, whereas factors such as a supportive learning environment and positive staff attitudes have been associated with readiness to accept change.^{67,72,73,76,77} Demonstrated within the studies in this review, was the capacity for the local environment to influence implementation of new care models across rehabilitation settings. Implementation issues, such as the absence of an organisation-wide rehabilitation culture, as well as negative attitudes of staff and patients, were persistent in several studies.^11,45,50,58 In some instances, negative attitudes of staff or patients, and their local beliefs was reported to hinder implementation, even if an organisation had a rehabilitation culture.⁶⁴ Engaging clinicians, management, and patients in care model development, with continuous monitoring and feedback, is likely to create a positive work culture. Bayley and colleagues particularly highlighted the importance of clinicians’ beliefs, attitudes, and strong organisational support to promote evidence-based care in rehabilitation.³¹

Examining how organisational culture and attitudes interact may be useful for designing new care models. A number of studies identified communication gaps at the organisational level as barriers to implementation.^{7,39,45,53,58} This was particularly noticeable when a new care model overlapped with an existing model or was perceived as adding to staff workload. Effective communication among healthcare providers is a known facilitator in establishing a good interdisciplinary teamwork environment in healthcare.^13,77,81

Prior knowledge, skills, and experiences of clinicians with a high degree of subject expertise were found to facilitate the implementation of a new model of care, along with support from patient families.^{44,54,58,59,62} New care models with support and motivation from peers and management were found to be effective in terms of patients’ adherence and were also identified as sustainable in the long-term.^{6,37,39,44,61,76,79,82} This review highlights the possibility of increasing a new care model’s acceptance and sustainability by leveraging positive views towards the new intervention or care delivery models. However, a lack of motivation can have the reverse effect, leading to implementation barriers. Manhas and colleagues demonstrated that a lack of motivation and unsupportive leadership were key challenges to the sustainability of their rehabilitation care model.⁶¹

In this review, the implementation process was found to be influenced by the resources available. The most frequent cause of resource unavailability was staff turnover. Various strategies to reduce staff turnover, such as building a strong rapport among healthcare providers and explicit measures, such as celebrating achievements, or providing mentoring support were identified as useful strategies.^38,72 A lack of access to information and a lack of knowledge and practical skill to deliver the care model elements were reported as barriers in several studies,^35,45,58,62 demonstrating the need to design any care models with frequent training sessions and to provide professional support to staff during implementation. Similarly, Antypas and colleagues⁸³ also considered implementation resources and adequate staff as important factors in successful implementation of care models.⁸³

The review identified a lack of funds as an implementation barrier for new rehabilitation care models, particularly when the rehabilitation was carried out in a home-based setting.^11,37,56,73 Two studies offered patients reimbursement or complimentary sessions to offset individual patient rehabilitation costs.^36,38 However, cost barriers highlight the importance of ensuring necessary funding is available prior to starting implementation of a care model. Adequate long-term financial resources are crucial in terms of long-term sustainability.

The review also brought to the fore issues with IT infrastructure as a key barrier. Common IT issues reported were complex online applications or apps, participants’ lack of access to the internet and lack of capability to use apps. Problems with IT highlight the necessity of creating a care model that is easy and adaptable to the needs of the participants. The review findings are consistent with other studies that have recommended the customisability and personalisation of technology to make applications easy to operate independently for a wide range of potential users.⁸

A lack of a local implementation champion was noted as a barrier.^44,62 Engaging local champions has been found to facilitate implementation delivery.^62,68 Having highly motivated and committed staff has been reported to facilitate care model delivery and encouraged patients to undertake rehabilitation sessions on a regular basis.³⁵ However, in other studies, staff reported that rehabilitation sessions were too time consuming and implementing new care elements might adversely affect their private practice.¹¹ These diverse examples illustrate the importance of engaging with staff and maintaining staff motivation during implementation of new care models.^66,69,72

The review found that new care models that were customised to meet the requirements and circumstances of the local setting were shown to have more staff engagement and were noted to have flexible delivery options when implemented in practice.^15,16,84 The importance of taking into account the local environment and the needs of all stakeholders is critical in designing the implementation of models of care in rehabilitation. Achieving integrity, feasibility, acceptability, and adherence requires a co-design approach to developing a care model that incorporates patients’ perspectives, staff expertise, and experience in healthcare settings. Evidence shows how co-designed or participatory designs with staff, patients, and stakeholders in different settings can translate evidence into acceptable and feasible solutions.⁸⁵ However, the review also found that tailoring interventions or care models to the specific needs of a local context had significant complexities, particularly when attempting to maintain fidelity to the original evidence base. Inconsistencies between the expectations of patients and healthcare professionals were evident regarding patients’ ability and acceptability of the model within the local environment. This highlights the need to be prepared to adapt an intervention or care model while ensuring its effectiveness.^50,52,57,58 Furthermore, the participatory method fosters confidence and trust between patients and staff, ensuring the fidelity and sustainability of a care model.⁸⁵

Relationships between the facilitators and barriers

Some facilitators and barriers identified in the review had intersecting roles in the implementation of new care models across rehabilitation settings. For example, the implementation process was hindered in some studies due to staff turnover, resulting in staff with little to no experience implementing the care model or new staff trying to learn new implementation skills in a limited time.^57,62,64 In other studies, due to staff shortages and extreme workload pressure, clinicians prioritised their regular work rather than implementing the new care model, which they perceived to take additional time.^{29,31,39,40,50,59,61,71,72} Other facilitators and barriers had dual roles within the studies, operating as both a facilitator and a barrier. For example, the implementation process in some studies were facilitated by prioritising the expertise, knowledge, and abilities of clinicians and staff regarding the care model.^11,48,49,55 In other studies, the lack of prior experience and expertise is thought to be a barrier to implementation process.^39,57 A similar intersecting pattern emerged between innovation complexity and IT system challenges. In several studies, complex care models were described as difficult to implement and closer examination revealed that the perceived complexity often stemmed from inadequate or malfunctioning IT systems that supported the model.^{9,31,41,50,55,58,66,67,72,77} Conversely, when IT systems were well-integrated and aligned with the new care model, the innovation was perceived as more intuitive and manageable.^{28,44,56,58,68,70}

Implications of the review

This review identified that although the type of care model, health condition, and care setting may differ, similar factors can enable or hinder the implementation of new care models in rehabilitation. The review also highlighted the intersecting nature of factors and that some factors that might work as facilitators in one domain and barriers in another domain. The review has shown that planning for implementation and tailoring implementation strategies to suit the context are crucial for successful implementation. Studies that had complex care models, inadequate implementation planning, high staff turnover, poor communication, and that were not adequately resourced had limited success with implementation.^86,87 Care models should be designed according to the local context and in a user-friendly manner. Access to knowledge and information about the care model should be available both to the implementation providers and recipients.

Any organisation considering implementing a new care model in rehabilitation should prioritise the development of a supportive organisational culture that promotes teamwork, collaboration, and ensure there is committed support from organisation leaders and staff. Arranging practical training sessions for staff to demonstrate model elements, and continuous monitoring with regular feedback can all facilitate a positive teamwork environment and improve staff confidence in care model delivery.^11,35,45

Strengths and limitations

The review strengths include a comprehensive search strategy involving six databases with a medical librarian involved in the development of key search terms. The PRISMA guidelines were followed, and multiple reviewers were involved in study selection, data extraction and the narrative synthesis. Any disagreement was discussed among the reviewers and resolved by mutual consensus. As to limitations, the search strategy did not include grey literature or articles published in languages other than English. The review excluded studies reporting on the implementation of virtual care models or telerehabilitation, which may have resulted in additional information on facilitators and barriers being overlooked. The facilitators and barriers identified were those reported by study authors, yet the classification of factors using the CFIR was subjective. Potential links between the facilitators and barriers are unknown.

In conclusion, this review highlights the importance of planning when implementing new models of care in rehabilitation to harness facilitators and to address potential barriers prior to implementing new models of rehabilitation care in a real-world environment. The facilitators and barriers to implementation identified by the review can be used to aid the optimal design and implementation of new models of care in rehabilitation.

Supplemental material

Supplemental material - Facilitators and barriers to implementing new models of care for patients in a rehabilitation care setting: A systematic review

Supplemental material for Facilitators and barriers to implementing new models of care for patients in a rehabilitation care setting: A systematic review by Nabila Binte Haque, Reidar P Lystad, Jeffrey Braithwaite and Rebecca J Mitchell in Journal of Health Services Research & Policy

Footnotes

Acknowledgements

The authors thank Mr Jeremy Cullis, librarian at Macquarie University for his contribution to literature search terminology.

ORCID iDs

Nabila Binte Haque

Reidar P Lystad

Rebecca J Mitchell

Ethical consideration

Not applicable, as this is a review of the literature.

Author contributions

Nabila Binte Haque: Methodology, Investigation, Visualization, Writing - Original Draft, Writing - Reviewing and Editing; Reidar P Lystad: Conceptualization, Methodology, Investigation, Writing - Reviewing and Editing, Visualization, Supervision; Jeffrey Braithwaite: Writing - Reviewing and Editing, Supervision; Rebecca J. Mitchell: Conceptualization, Methodology, Investigation, Writing - Reviewing and Editing, Supervision.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was funded by a grant from the NSW Ministry of Health and a Macquarie University international research excellence scholarship (iMQRES).

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

All data generated or analysed during this study are included in this published article [and its supplementary information files].*

Supplemental material

Supplemental material for this article is available online.

Appendix

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