ATrain Education

 

Continuing Education for Health Professionals

Stroke: Emergency Care and Rehabilitation

Module 9

Post Stroke Rehabilitation

There is no doubt that, at least in developed countries, more people are surviving stroke than did in the past. New medications and advances in prehospital and emergency medicine mean people are surviving strokes that would have killed them in the past. Post stroke rehabilitation is advancing also. Technologic advances, information gleaned from brain imaging, and new theories about motor control have led researchers and clinicians to consider new and more effective approaches to rehabilitation.

Although the incidence* of stroke is decreasing (at least among white Americans), because people are living longer, the number of strokes each year is increasing (Siegler et al., 2013). Unfortunately, many of those who survive a stroke experience chronic deficits that affect their quality of life, mobility, and independence. Because of this, there is an urgent need to improve our understanding of the recovery process and develop therapeutic strategies to improve post stroke outcomes.

Incidence: Incidence is the number of new cases of a condition, symptom, death, or injury that develop during a specific time period, such as a year. Incidence shows the likelihood that a person in that population will be affected by the condition (National Library of Medicine).

For those who survive a stroke, most (about two-thirds) receive rehabilitation services of some type lasting for an average of about 15 days (Cullen et al., 2013). Rehabilitation usually starts in the acute care hospital. Once the patient is stable, post stroke rehabilitation generally continues in one of four places: an inpatient rehabilitation facility (IRF), a skilled nursing facility (SNF), an outpatient facility, or a home-based rehab program.

Whatever the location, the goal of post stroke rehabilitation is to improve motor, sensory, and cognitive function and, when possible, encourage a return to independent living. Focus is on mastery of basic and complex activities of daily living as well as household and community mobility. Cognitive retraining, speech and language skills, swallowing, and safety awareness are key components.

Rehabilitation has become an integral part of post stroke care. It has been shown to improve outcomes, decrease morbidity, and increase independence. Not surprisingly, we are learning from research that organized stroke unit care provided by nurses, doctors, and rehabilitation therapists is consistently associated with better outcomes (Langhorne, 2013).

Unfortunately, many new techniques and breakthroughs have not been implemented on a day-to-day basis in post stroke rehabilitation. In the United States, in the absence of a centralized healthcare system, care is fragmented and inconsistent and post stroke services are spread across an array of facilities and practitioners. Let’s begin by looking at where post stroke takes place.

In the United States, there are more than 6,000 acute care hospitals managing nearly 1 million beds (AHA, 2014a). As soon as possible following an acute stroke, patients are evaluated for therapy and may begin a basic rehab program within a day or two. Once stabilized, patients are typically transferred to what Medicare refers to as post-acute care. All told, there are nearly 29,000 post-acute care providers in the United States (NHPF, 2012).

In urban areas with greater resources and large numbers of Medicare patients, post-acute care may be provided in an inpatient rehabilitation facility (IRF). In those areas without an IRF, post stroke rehab will likely take place within the acute care hospital or in a skilled nursing facility (SNF). Those with less severe symptoms may be discharged to home with home health services or receive services in an outpatient rehab clinic. The quality and quantity of post stroke rehabilitation services vary widely depending on local healthcare policy, local culture, and resource availability (Cullen et al., 2013).

 

*CMS, 2011.
**All other settings include outpatient care, home, and other inpatient facilities.

Post Hospital Stroke Discharge Locations (MedPAC, 2013a)

Locations

Percentage

Inpatient rehab facilities (IRF) (n=1,165)

19%

Skilled nursing facilities (n=15,000)

25%

Home health agencies (*n=>11,000)

12%

**All other settings

44%

 

Unfortunately, in the United States there are no consistently applied clinical guidelines for what type of care a patient should receive following a stroke. Typically, the decision of where to receive rehab is made in the acute hospital, often by the patient’s physician, ideally in consultation with nursing and therapy. The American Heart Association/American Stroke Association (AHA/ASA) has called for this discharge decision to be interdisciplinary, taking into account the patient’s medical condition and family situation. AHA/ASA has also recommended the establishment of “stroke systems of care.” This means a healthcare organization makes a commitment to stroke prevention, community education, emergency medical services, acute and sub-acute stroke care, rehabilitation, and performance review of stroke care delivery (Jauch et al., 2013).

Not surprisingly, healthcare organizations that have implemented stroke systems of care report improved outcomes; patients treated in such a setting are more likely to be alive, independent, and living at home than those treated in any other setting, a benefit that lasts at least for a decade (Meretoja et al., 2010).

Rehab in the Acute Hospital

In the acute care setting, rehabilitation ideally begins immediately after a diagnosis of stroke has been confirmed and the patient has been stabilized. In this setting, patient mobilization, emotional support, and education are priorities. Assessment of general health and prevention of secondary stroke and stroke-related complications are critical components of care in the acute phase (Sunnerhagen et al., 2013).

As soon as the patient’s medical and neurologic condition permits, a clinician experienced in rehabilitation should perform a screening exam to determine if the patient is appropriate and ready for more intense rehabilitation. The screening should incorporate medical information, a neurologic exam, a standardized disability instrument (eg, activities of daily living) and a mental status screening test (Teasell et al., 2013a).

During the days and weeks following a stroke, patients with severe disability and those who have poor physical endurance or limited attention spans are usually managed in a low intensity rehab program, often in a skilled nursing facility. These programs may offer single or multiple therapies in an interdisciplinary setting 1 to 3 hours a day, 3 to 5 days a week (Teasell et al., 2013)

The general belief has been that patients with severe disability will not benefit from intensive rehab as much as those with milder strokes. However, the results from a recent study involving 196 non-ambulatory stroke patients (Teasell et al., 2013) demonstrated that patients with severe stroke can achieve impressive rehabilitation goals. In the study, patients were admitted to a specialized, enriched, multidisciplinary rehabilitation program for a period of close to 3 months. Upon completion, 43% of patients were able to return home and 28% were no longer wheelchair dependent (Teasell et al., 2013).

It has become increasingly common to provide very early rehabilitation, often less than 24 hours after the stroke has occurred. A multi-center study called AVERT (A Very Early Rehabilitation Trial) tested the safety and feasibility of very early mobilization. Stroke patients randomly received either standard care or very early mobilization. The study showed that there was no harm to patients in the very early mobilization group compared to those who had standard care (Jauch et al., 2013).

The study also showed that early mobilization lessens the likelihood of complications such as pneumonia, deep vein thrombosis, pulmonary embolism, and pressure sores (Jauch et al., 2013). A grant to conduct the larger study, to test the effectiveness of very early mobilization has been obtained (clinicaltrials.gov, 2014). The larger trial is underway in the United Kingdom, Australia, Canada, New Zealand and Southeast Asia (Teasell et al., 2013).

Inpatient Rehabilitation Facilities

Inpatient rehabilitation facilities (IRFs) are a type of acute-care hospital. They provide intensive, team-based rehabilitation to patients after an injury, illness, or surgery. There is strong evidence that inpatient rehab, initiated rapidly after stroke through multi-disciplinary teams within dedicated stroke units, represents the option with the strongest evidence base and thus is considered gold standard care for recovery in the post-acute phase (Jan et al., 2013).

In the United States, there are about 1,165 certified inpatient rehab facilities, 80% of which are hospital-based. Overall, the number of IRFs has been slightly but steadily declining since 2005 (MedPAC.gov, 2013). In 2013, stroke patients represented about 19% of patients treated in IRFs with an average stay of 15 days (Dobson & DaVanzo, 2014).

Rehabilitation at an inpatient rehabilitation facility must be directly supervised by a rehabilitation physician (physiatrist). Services are comprehensive and include physical and occupational therapy, speech–language pathology, around-the-clock rehab nursing, and prosthetic and orthotic services. If the facility is free-standing—rather than a department in an acute-care hospital—it must have on staff a full-time medical director (with training or experience in inpatient rehabilitation). If hospital-based, a qualified physician must provide services for 20 hours per week (MedPAC, 2013a).

Inpatient rehabilitation facilities tend to be concentrated in highly populated states in areas with large Medicare populations. Overall, for Medicare beneficiaries:

  • 69% live in a county that has at least one IRF
  • 44% live in a county with two or more IRFs
  • 31% live in a county that does not have an IRF (MedPAC, 2013a)

Despite demonstrably better outcomes, inpatient rehab facilities may be adversely affected by proposed changes in Medicare’s payment system. One proposed change, “bundling,” would pay for an “episode of care,” which would include a hospital stay and 30 days of care following discharge from the hospital (MedPAC, 2014).

Another proposal, called “site-neutral” payments, stems from the Medicare Payment Advisory Commission Commission’s (MedPAC) position that Medicare should not pay more for care in one setting than in another if the care can be safely and efficiently (that is, at low cost and with high quality) provided in a lower cost setting” (MedPAC, 2014).

Yet another change is the MedPAC recommendation that physicians no longer be required to see patients at least 3 times per week and IRFs no longer be required to provide intensive therapy to patients each day.

The proposed changes are not without controversy and are expected to adversely affect IRFs in particular. According to Toby Edelman of the Center for Medicare Advocacy, site-neutral payments would likely reduce payments to IRFs, reduce the availability of IRFs for Medicare patients, and increase cost-sharing. Post-acute bundling would also likely shift Medicare patients from IRFs to SNFs (Edelman, 2014). Click here for more information.

On January 15, 2015, MedPAC finalized its recommendation to Congress that Medicare should begin to move toward site-neutral payments where there is clear overlap in the services provided, such as for certain patients served by SNFs and IRFs. The American Hospital Association, an industry trade group, has expressed concerns about the payment changes. “We have a number of concerns about MedPAC’s IRF-SNF site neutral recommendation, including that it may lead to the provision of SNF-level care for beneficiaries who actually would have achieved a better outcome if they had received IRF-level care,” said Joanna Hiatt Kim, American Hospital Association vice president of payment policy.

Rehab at a Skilled Nursing Facility

In the United States, there are more than 15,000 skilled nursing facilities (SNFs) managing more than 1.6 million beds. Nationwide, Medicare Part A is the primary payer for about 14% of those receiving services at a skilled nursing facility—usually as part of a department offering generalized rehabilitation services. In 2009 about 14% of Medicare admissions to SNFs involved stroke patients (AHCA, 2012).

In the world of skilled nursing facilities, an ever-higher percentage of patients is being admitted for short-term rehab; in fact, the majority of patients admitted to a SNF are people who need skilled services or rehabilitation following an acute injury or illness. Of the 3.7 million individuals who received care in a nursing facility in 2009, only about 23% resided in the facility for at least a year. Of the remaining 2.9 million, 80% were admitted for short-term rehabilitation covered by Medicare (AHCA, 2012).

Post stroke rehabilitation services carried out in a SNF can vary wildly depending on the size of the SNF, location (rural vs. urban), the availability and expertise of the therapists, and nurse and nursing assistant staffing. Physician oversight is minimal, nursing staff are not required to have expertise in rehabilitation, and therapists are (by necessity) generalists, rather than stroke specialists. The majority of direct patient care is provided by nursing assistants who receive little of no training in stroke care. Often there is little space for rehab—sometimes only a couple of converted patient rooms—and very little specialized equipment. There are fewer requirements for patients entering rehab at a SNF compared to an IRF; only 1.5 hours of therapy are required each day (Mon-Fri).

To qualify for post stroke rehab at an SNF:

  • There must be a need for skilled nursing care 7 days a week or skilled therapy services at least 5 days a week;
  • A patient must have been formally admitted as an inpatient to a hospital for at least 3 consecutive days. Patients must enter a Medicare-certified skilled nursing facility within 30 days of leaving the hospital;
  • A patient must have Medicare Part A before discharge from the hospital; and
  • There must be a need for care that can only be provided in a SNF (Medicare Interactive, nd).

If these requirements are met, Medicare generally covers the skilled nursing facility care, including care needed to improve a patient’s condition or maintain their ability to function. Medicare should cover skilled care if it helps a patient to maintain functional abilities or prevents or slows a decline in function. Between 2005 and 2009, the average length of stay for a stroke patient in a SNF was approximately 32 days (Dobson & DaVanzo, 2014).

 

Source: Center for Medicare Advocacy, 2014. Reprinted with permission.

Requirement

IRFs

SNFs

Physician oversight

Rehabilitation physicians must see patients at least three times per week

Physicians must see residents within 14 days of admission and then every 30 days

Registered nurse staffing

24 hours per day

8 hours per day

Therapy services

Intensive; often described as at least three hours per day

No requirements; Medicare reimbursement rate depends on amount of therapy SNF says it provided

Average length of stay

15 days

32 days

 

Long-Term Care Hospitals

Although most people who need inpatient hospital services are admitted to an acute-care hospital for a relatively short stay, some may need a longer hospital stay. Long-term care hospitals (LTCHs) are certified as acute-care hospitals, but focus on patients who are severely ill and who, on average, are hospitalized for more than 25 days. Prior to the 1980s most LTCHs had evolved from tuberculosis and chronic disease hospitals. The late eighties and early nineties saw the growth of LTCHs, although they were generally privately owned and served mostly ventilator-dependent patients; in the 1990s LTCHs began to develop within acute hospitals. As of 2011, there are 436 Medicare-certified LTCHs nationwide (MedPAC, 2013b).

LTCH patients are, in general, more severely ill than those in acute care hospitals; many are transferred from an intensive or critical care unit. LTCHs specialize in treating patients who may have more than one serious condition, but who may improve with time and care, and return home. LTCHs typically provide comprehensive rehabilitation, respiratory therapy, head trauma treatment, and pain management.

The average length of stay for patients in LTCH is 27 days, compared to 5 days for general acute hospitals, and almost 7 days for ICUs in general acute hospitals (AHA, 2014b).

Comprehensive Outpatient Rehab Facilities (CORFs)

CORFs provide coordinated outpatient diagnostic, therapeutic, and restorative services at a single fixed location for the injured, disabled, or sick individuals. Physical therapy, occupational therapy, and speech-language pathology services may be provided in an off-site location. A CORF must minimally offer physician services, physical therapy, and social or psychological services. CORFs differ from general outpatient rehab facilities in that, in addition to physician and therapy services, a fully staffed CORF must provide these additional services:

  • Respiratory therapy
  • Prosthetic and orthotic services
  • Nursing services
  • Durable medical equipment

Besides CORFs, about 30% of stroke survivors receive therapy services in a general services outpatient clinic (Higashida et al., 2013), which is typically provided 3 times per week. Outpatient therapy can also be provided in other locations:

  • Offices of privately practicing therapists
  • Medical offices
  • Outpatient hospital departments
  • Outpatient rehabilitation facilities (other than a CORF)
  • Skilled nursing facilities (SNFs)
  • At home, from privately practicing therapists (CMS, 2014)

Home Health Rehabilitation

Home health agencies, with 12,000 throughout the United States, are the most commonly used post-acute care provider, with 3.4 million Medicare users (NHPF, 2012). Home health agencies provide services through Medicare for homebound patients, usually upon discharge from an inpatient rehab facility or skilled nursing facility. The patient’s physician must certify that the patient is homebound and state the reasons why skilled services are needed. Outpatient and home-based therapy are less expensive alternatives to inpatient therapy following a stroke and, in some cases, may be just as effective.

Early-Supported Discharge

Early supported discharge (ESD) is an approach that provides interdisciplinary rehabilitation in the home instead of in a hospital. The early supported discharge model links inpatient care with community services and allows patients to be discharged home with support of the rehabilitation team.

ESD is common in Great Britain, where the National Health Service has established the goal of facilitating early supported discharge to home for 40% of stroke patients. Difficulties with access to care, variations in the definition of ESD, and staffing shortages have limited the number of people who receive these services.

A 2012 Cochrane review has provided evidence that ESD is cost effective, can reduce long-term dependency, and results in positive outcomes for stroke patients. A review of 14 trials involving nearly 2,000 participants who received ESD services from doctors, nurses, and therapists showed that ESD patients returned home earlier and were more likely to remain at home in the long term and to regain independence in daily activities when compared to those who received conventional rehab services. The best results were seen with well-organized discharge teams and patients with less severe strokes (Fearon & Langhorne, 2012).

Comparing Outcomes

When comparing outcomes for stroke patients receiving rehab services, most research has looked at IRFs and SNFs, where care differs significantly. A study involving 20% of Medicare beneficiaries, matched on demographic and clinical characteristics, looked at the difference in 2-year outcomes between patients discharged from IRF and SNF rehab. Rehabilitation in IRFs leads to lower mortality, fewer readmissions and ER visits, and more days at home than rehabilitation in SNFs for the same condition. This suggests that the care is not the same at IRFs and SNFs and that the care setting has an effect on patient outcomes (Dobson & DaVanzo, 2014).

In terms of mortality, even though stroke patients treated in IRFs were discharged significantly sooner than patients treated in SNFs (16.5 days earlier), among matched stroke patients, IRF patients lived longer than SNF patients. Nearly half of those discharged from a SNF died within 2 years while only a little more than a third died within 2 years of discharge from an IRF. Stroke patients discharged from an IRF rehab program lived nearly 97 days longer than those discharged from a SNF rehab program (Dobson & DaVanzo, 2014).

These differences were apparent for home health and outpatient services as well. When comparing IRFs and home health/outpatient services, those who went to an IRF had statistically significant improvements in applied cognitive function compared to those who received only home health or outpatient services. These differences were statistically significant, were evident six months after the stroke, and persisted even after controlling for patient characteristics such as age, stroke severity, pre-stroke function, the burden of co-morbid illnesses, as well as treatment hours (Chan et al., 2013).

Despite high-level evidence that stroke patients experience better outcomes when treated by interdisciplinary stroke specialists, this care is not available to many stroke patients. There are a number of reasons for this:

  • Lack of access to specialist hospital staff
  • Fluctuating or small-stroke patient numbers when a critical mass is required
  • Cultural resistance to change (Brusco et al., 2014)
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