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Background: Despite recent advances in acute stroke intervention, secondary prevention strategies are lacking. Physical activity (PA) is the second-largest predictor of stroke and a cornerstone of secondary prevention therapies. Interventions to promote PA post-stroke include components aimed at reducing sedentary behaviour and increasing participation in lifestyle PA and structured exercise. Despite guidelines to adapt PA to individuals’ needs, there is no evidence on the empirical development of adaptive PA interventions post-stroke. This study will explore patient, caregiver and multidisciplinary healthcare professional perspectives on the design and delivery of adaptive, personalised PA interventions, delivered using a smartphone application, following mild-to-moderate stroke. Findings will directly inform the protocol of an experimental trial, using a novel adaptive trial design. Methods: A descriptive qualitative study will be undertaken to inform the design, delivery and subsequent acceptability of a smartphone application to reduce sedentary behaviour and promote PA post-stroke. Data will be collected via one-to-one interviews and focus groups and analysed according to a six-step thematic analysis. Findings will be reported in accordance with the consolidated criteria for reporting qualitative research (COREQ) checklist. One-to-one interviews and focus group interviews will be conducted with three stakeholder groups: 1) People post-stroke, who are independently mobile, without communication and cognitive deficits, living in the community, and without other diagnosed neurological conditions. 2) Caregivers (formal and informal) involved in post-stroke care. 3) Healthcare professionals who are members of multidisciplinary stroke teams. Ethics and dissemination: Ethical approval has been granted by the Faculty of Education and Health Sciences Research Ethics Committee at the University of Limerick [Ref: 2019_10_03_ EHS]. Findings will be shared locally with all stakeholder groups, submitted for publication, and will inform the protocol and conduct for a novel and flexible experimental trial, examining the effectiveness of an adaptive PA intervention post-stroke.

Introduction & Description: The NRH Paediatric Programme was reviewed within the context of the decision to maintain complex paediatric neurological rehabilitation at the NRH, and the Paediatric Clinical Programme Model of Care. This framework formed the basis for a change management project within the current service to reconfigure resources and provide new ways of service delivery. The objectives of quality, access and value were key. The programme has moved to a “children served” approach and broadened the range of service options. Aim & Theory: The project was initiated in response to key challenges to the NRH Paediatric Service including lengthy waiting lists over extended staff and unnecessary variation in patient experience. The aim was to align the NRH Paediatric service with the models of care developed HSE National Paediatric Clinical Programme and the Rehabilitation Medicine Programme. Targeted population: The NRH PAEDS Programme remains the only service of its kind in Ireland with little change in staffing levels over many years despite a substantial increase in referrals, more complex cases and a change in international best practice on the necessity for review by a paediatric specialist neuro rehabilitation team of identified children. The populations served by this project includes not only all the children under the care of the programme but also the treating team. Timeline: The Implementation of the Project was given a timeframe of 6 months. This was following a period of review/analysis of current systems operating within the service. Highlights: The aligning of priorities across all stakeholders ie programmatic priorities, Organisational priorities, health services priorities, team priorities, family priorities. Sustainability: The extensive consultation process undertaken supported multi-stakeholder collaboration and buy-in. Implementing and sustaining changes which are representative of the views of key stakeholders and accepted as best practice is more sustainable than enforcing a pathway that is not felt to be reflective of all important issues. Transferability: The principles underpinning the changes made & the management of same within the programme are consistent with international models of improvement science and thus applicable across other service. Conclusion: The project has already shown a reduction in waiting lists, more efficiency in terms of service delivery and greater predictability in terms of service planning. A further outcome is a reduction in unnecessary hospitalisation for children. Increased resources are being directed at integrated care via outreach and education to community services and schools. Discussion: Quality care is care which is patient centred. To be truly patient centred, a move away from individual service priorities is required with a focus on aligning priorities to support the patient/family. Lessons Learned: Implementation of the project required not only a change in processes, but a change in culture which underpinned the processes. Culture change requires significant investment in developing relationships with team and building trust. It doesn’t happen overnight. Hearts and minds were won when the team could see how the change facilitated the overall shared objective which was to provide the service in line with international clinical guidelines.

Introduction: Trauma and rehabilitation networks in Ireland are largely underdeveloped and there is significant variance in patient pathway within and across acute hospital services, specialist rehabilitation services and post-acute regional or community based rehabilitation services. Currently, in the absence of established clinical pathways across existing acute and rehabilitation services, patient pathway is convoluted. For patients with the most complex and severest injuries access to complex specialist rehabilitation services is compromised and outcomes such as discharge to community is poor. The vision for this project was to develop an all systems approach to support the patient journey for patients with Spinal Cord Injury from acute hospitals, post-acute rehabilitation services, disability services and long term care. Short description of practice change implemented: The National Clinical Programme for Rehabilitation Medicine has developed a care pathway in collaboration with all key stakeholders which describe the ideal patient journey for all those with a spinal cord injury, including those who are ventilator dependent. This is the first time such a pathway has been developed and will promote a patient centred approach to the management of this cohort of patients while also giving clear parameters against which patient journey can be measured going forward. Currently there is a cohort of patients in Ireland with high level spinal cord injury including some who remain in need of chronic ventilation who are unable to be served through within existing services. These patients are experiencing prolonged stays in acute hospital and some are unable to access complex specialist rehabilitation services. Implementation of the pathway will see patients who are ventilator dependent being able to access specialist rehabilitation services in Ireland for the first time and will also see the possibility of a discharge home realised for many. Aim and theory of change: The reduction in unnecessary variation in the care pathway of patients with spinal cord injury was felt to be achievable through the development of an ICP in collaboration with all key stakeholders. Targeted population and stakeholders: The ICP for patients with spinal cord injuries spans numerous service delivery sites, as such, collaboration with a wide number of stakeholders including acute hospitals, critical care, rehabilitation services, disability and community services, patients and patient support groups was necessary. Timeline: This project was identified as an area needing development in the 2016 workplan of the Rehabilitation Medicine Programme. Highlights: The project is small in numbers but significant in terms of process changes. It requires services working together across organisational boundaries in a way that is not often seen within the Irish healthcare system. Implementation will see patients with complex disability being able to access services in Ireland which they previously would have had to travel oversees to access. Comments on sustainability: The Principles supporting the care pathway are reflective of evidence based practice. The extensive consultation process undertaken by the programme has supported multi-agency collaboration and buy-in which will sustain this new way of working. The parameters set out in the patient pathway will afford us the opportunity to objectively measure patient journey and identify unnecessary variation in a way previously not possible. Comments on transferability: While this pathway is for spinal cord injury, the underpinning principles should be consistent for all with a need for specialist rehabilitation service and thus applicable across other diagnostic groups. Conclusions: The high level objectives for the project are: Process Improvements: - Improved access to both the National Spinal Unit (NSIU) and NRH for all patients requiring the tertiary level services they provide - Allow access to post acute specialist rehabilitation services at the NRH, particularly for those who are ventilator dependent Quality: - Reduce the number of patients being discharged back to acute hospital setting post rehabilitation services - Improve patient experience Discussions: Quality care is care which is patient centred. To be truly patient centred, a move away from individual service priorities is required with a focus on aligning priorities to support the patient journey. Lessons learned: The patient voice should be central to all health care planning

Introduction and background: This abstract outlines the standardisation of the existing Waiting List Management System of the Brain Injury Programme at the National Rehabilitation Hospital, Dublin, Ireland to improve access to, and integration of, services from the acute hospital to the post-acute rehabilitation setting. Analysis of baseline data revealed significant delay for patients accessing inpatient specialist rehabilitation beds with 47% of patients waiting longer than the targeted 70 days (range: 5 321 days). The aim of the initiative was that “All patients will have equitable access within a defined target (i.e. less than or equal to 70 days waiting) to inpatient specialist rehabilitation beds provided by the Brain Injury Programme at theNationalRehabilitationHospital”. Key Findings: A system of pooled-shared waiting lists has been introduced from acute hospital to rehabilitation setting since January 2013. The percentage of patients waiting longer than 70 days for admission to NRH has now dropped from 47% to 29% and average days waiting for admission has dropped from 97 to 54. This has resulted in increased access for patients and that clinical responsibility remains with a consultant physician at all times. This system now ensures that patients referred are admitted into beds coordinated to meet their rehabilitation needs and under the medical care of their own designated consultant physician. Access was measured as ‘days waiting’ from the time of entry to ‘the list’ on the hospital’s Patient Administration System. Significant waste and duplication and significant variation was identified in how patient information was managed and communicated. Processes were not consistent or standardised and this subsequently led to delay in responding to referrals, loss of referral information, delay in patients being put on the system and significant delay in admission of patients. This subsequently led to significant concerns for patient safety, service cost and equity of access. In a direct response to concerns for the safety of patients waiting, the responsibility for monitoring of patients waiting and decision making for patients to be admitted to dedicated specialist beds on a weekly basis was given to a multidisciplinary team. 3 World Congress on Integrated Care, Mexico City, Mexico, 19-21 November, 2015 International Journal of Integrated Care – Volume 15, 17 Nov – URN:NBN:NL:UI:10-1-117305 – http://www.ijic.org Feedback obtained from service users and referrers indicated the need for a transparent, clear and efficient referrals and waitlist management system. Drivers identified within the Programme included the need for a comprehensive ‘whole-programme’ waiting list for admission decisions and bed management in four ward areas. A key factor in managing the change was to incorporate a seamless transition between the ‘old’ and the ‘new’ systems and the extension of our current IT (Patient Administration System PAS) system to support administrative staff. Highlights: The project team ‘championed’ the change proposed through all senior management channels. Buy-in from the Executive Management Team and the Medical Board of the hospital has been key to the success of this initiative. Concerns from clinicians and resistance to the change were carefully managed. Consultation with the hospital’s Medical Board and Medical Administration ensured that the change was in line with clinical best practice and in the best interests for our patients’ safety and wellbeing. Conclusion: Related to the Project and maybe as a direct result of the improvements shown, there has been a significant reconfiguration of beds and allocation to consultant physicians in the Programme. Each rehabilitation unit now has one dedicated Consultant led team with a new bed management system in place. The hospital has also been successful in securing funding for 10 dedicated ‘Early Access’ beds for patients with less complex medical and nursing needs who benefit significantly from earlier access to the multi-disciplinary therapy team. Conference abstract Spanish Introduccion y antecedentes: Este resumen describe la estandarizacion de la existente lista de espera para el Programa de Lesiones Cerebrales del Hospital Nacional de Rehabilitacion en Dublin, Irlanda, para mejorar el acceso y la integracion de los servicios del hospital de agudos para el ajuste de la rehabilitacion post-aguda. El analisis de datos de referencia revelo un retraso significativo para los pacientes que acceden a camas de rehabilitacion especializadas para pacientes hospitalizados con el 47% de los pacientes que esperan mas tiempo que los dirigidos de 70 dias (rango: 5 321 dias). El objetivo de la iniciativa era que "todos los pacientes tendran acceso equitativo dentro de un objetivo definido (es decir, menor o igual a 70 dias de espera) a camas de rehabilitacion especializadas para pacientes hospitalizados proporcionados por el Programa de Lesiones Cerebrales en el Hospital Nacional de Rehabilitacion". Principales conclusiones: Un sistema de agrupacion compartida de las listas de espera se ha introducido al centro de rehabilitacion hospitalaria grave desde enero de 2013. El porcentaje de pacientes que esperan mas de 70 dias para la admision a HNR ahora ha bajado del 47% al 29% y el promedio de dias de espera para el ingreso se ha reducido de 97 a 54. Esto se ha traducido en un mayor acceso para los pacientes y que la responsabilidad clinica permanece con un medico consultor en todo momento. Este sistema ya se asegura de que los pacientes derivados son admitidos en camas coordinados para satisfacer sus necesidades de rehabilitacion y bajo el cuidado medico de su propio medico asesor designado. El acceso se midio en "dias de espera" desde el momento de la entrada en 'la lista' en el Sistema de Administracion de Pacientes del hospital. Se identificaron residuos significativos y la duplicacion y variacion significativa en la forma de la informacion del paciente fue gestionada y comunicada. Los procesos no fueron consistentes o estandarizados y esto posteriormente llevo a la demora en la respuesta de las referencias, la perdida de informacion de referencia, retraso en los pacientes que se ejerce sobre el sistema y retraso significativo en el ingreso de los pacientes. Esto condujo posteriormente a las preocupaciones importantes para la seguridad del paciente, el costo del servicio y equidad en el acceso. En una respuesta directa a las preocupaciones por la seguridad de los pacientes en espera, la responsabilidad de la vigilancia de los pacientes que esperan y lo que para los pacientes que deciden ser admitidos en camas especializadas dedicadas semanalmente se le dio a un equipo multidisciplinario. La votacion obtenida de los usuarios del servicio y los referentes indico la necesidad de un sistema transparente, y eficientes referencias y sistema de gestion de lista de espera. Los conductores identificados dentro del programa incluyen la necesidad de un programa de lista todo integrado para las decisiones de admision y gestion de las camas, esperando en cuatro zonas del barrio. Un factor clave en la gestion del cambio era incorporar una transicion sin problemas entre 3 World Congress on Integrated Care, Mexico City, Mexico, 19-21 November, 2015 International Journal of Integrated Care – Volume 15, 17 Nov – URN:NBN:NL:UI:10-1-117305 – http://www.ijic.org el "viejo" y los "nuevos" sistemas y la extension de nuestro actual de TI (Sistema de Administracion de Pacientes PAS) del sistema para apoyar al personal administrativo. Aspectos destacados: El equipo del proyecto "defendio" el cambio propuesto a traves de todos los canales de alta direccion. Comprar desde el Equipo de Gestion Ejecutiva y la Junta Medica del hospital han sido claves para el exito de esta iniciativa. Las preocupaciones de los medicos y la resistencia al cambio se manejaron con cuidado. La consulta con la Junta y medicina Administracion del hospital aseguro que el cambio esta en linea con la mejor practica clinica y en el mejor interes para la seguridad y el bienestar de nuestros pacientes. Conclusion: En relacion con el proyecto y tal vez como resultado directo de las mejoras que se muestran, se ha producido una reconfiguracion significativa de camas y la asignacion a los medicos consultores del Programa. Cada unidad de rehabilitacion tiene ahora un consultor dedicado, equipo dirigido por un nuevo sistema de gestion de la cama en su lugar. El hospital tambien ha tenido exito en la obtencion de financiamiento para 10 camas dedicadas de acceo temprano" para los pacientes con necesidades medicas y de enfermeria complejas que menos se benefician significativamente de un acceso mas rapido al equipo de terapia multidisciplinar.