What makes stroke rehabilitation patients complex? Clinician perspectives and the role of discharge pressure

BACKGROUND Approximately 80% of people who survive a stroke have on average five other conditions and a wide range of psychosocial issues. Attention to biopsychosocial issues has led to the identification of 'complex patients'. No single definition of 'patient complexity' exists; therefore, applied health researchers seek to understand 'patient complexity' as it relates to a specific clinical context. OBJECTIVE To understand how 'patient complexity' is conceptualized by clinicians, and to position the findings within the existing literature on patient complexity. METHODS A qualitative descriptive approach was utilized. Twenty-three stroke rehabilitation clinicians participated in four focus groups. RESULTS Five elements of patient complexity were identified: medical/functional issues, social determinant factors, social/family support, personal characteristics, and health system factors. Using biopsychosocial factors to identify complexity results in all patients being complex; operationalization of the definition led to the identification of systemic elements. A disconnect between acute, inpatient rehabilitation and community services was identified as a trigger for increased complexity. CONCLUSIONS Patient complexity is not a dichotomous state. If applying existing complexity definitions, all patients are complex. This study extends the understanding by suggesting a structural element of complexity from manageable to less manageable complexity based on ability to discharge.