Time/setting | Performance objectives, patients related | Internal determinants | |||
 |  | Performance skills | Coping ability | Lack of knowledge about access to rehabilitation | Lack of experience in relation to current situation |
 Day 0/ At the ED | Decide to participate in assessment of activity limitations |  |  | Receive relevant information about the assessment | Recognize that the ability to perform activities have changed due to illness |
 Day 0/ At the ED | Participate in performance-based assessment | Agree to be assessed in relation to perform activities |  |  | Experience possible change in performance of daily activities |
 Day 0/ At the ED | Decide to participate in further rehabilitation | Agree to participate |  | Achieve and consider information about opportunities for further rehabilitation | Recognize that the ability to perform daily activities have changed |
 Day 1 and after/ Patient home | Perform the training | Train to perform activities in a different way Train motor and process skills | Train in how to ask for assistance and/or help Consider information about possible strategies |  |  |
Time/setting | Performance objectives, staff related | External determinants | |||
 | Lack of information between hospital and primary care | Waiting time for rehabilitation after discharge | Inappropriate design of the patient’s home |  | |
 Day 0/ At the ED | Inform primary care about patient being discharged and plans for further rehabilitation | OT prescribe rehabilitation plan OT at the ED contacts therapists from primary care | Fast referral of the patient |  |  |
 Day 0/ At the ED | Change visitation procedure for patients referral |  | Make directly contact to therapists from primary care |  |  |
 Day 1/ Patient home | Access accessibility in the patients home |  |  | Screen the patients home in relation to safety risk when performing daily activities |  |
 Day 1/ Patient home | Make minor necessary changes in patients home |  |  | Remove carpets Arrange furniture |  |