North Carolina Online Stroke Rehabilitation Inventory

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1 North Carolina Online Stroke Rehabilitation Inventory Sarah Myer, MPH, CHES Community and Clinical Connections For Prevention and Health Branch Justus-Warren Heart Disease and Stroke Prevention Task Force North Carolina Division of Public Health

2 Stroke Rehabilitation Stroke continues to be a major cause of premature death and years of life lost. A growing body of evidence is concluding that coordinated stroke rehabilitation programs can reduce mortality rates, morbidity rates, and improve quality of life. Coordinated Stroke Rehabilitation includes input from the stroke survivor as well as providing medical, social, educational, vocational, and caregiver support therapies and services. (Go et al., 2013).

3 Justus-Warren Task Force State Cardiovascular Plan Goal 4 - Increase the proportion of North Carolinians who receive appropriate coordinated management of post-acute transitional care following cardiovascular events. Performance Measure: Number of rehabilitation facilities offering speech, occupational, and physical therapies to stroke patients. Telehealth Objective - Increase the capacity for providing appropriate treatment and services across the continuum of cardiovascular care.

4 N.C. Online Stroke Rehabilitation Inventory (2013) Partnership with the N.C. Heart Disease and Stroke Prevention Branch, N.C. Stroke Care Collaborative, participating hospitals, and a UNC-Greensboro Intern in the MPH program. Identify baseline measurements of stroke rehabilitation capabilities. Create a database of stroke rehabilitation contacts to facilitate data reporting in the future.

5 Great Lakes Regional Stroke Network Resource Inventory Great Lakes Regional Stroke Network (GLRSN)- Indiana, Illinois, Michigan, Minnesota, Ohio, and Wisconsin Paper Pencil Survey conducted in

6 N.C. Online Stroke Rehabilitation Inventory Tool Revised by Leigh Hayden, Paige Bennett, and Audrey Foster RED highlights denote changes we made to the GLRSN Inventory Section I - Demographics Section II System-wide Services Stroke Rehabilitation Settings Therapies and Services Section III- Facility-based Services Settings Challenges CARF (Commission on the Accreditation of Rehabilitation Facilities) Data Linkage Tele-rehabilitation Outcome Measures Clinical Trials and Continuing Education

7 Hospital Contacts Hospital contacts were obtained through a variety of methods. North Carolina Division of Health Service Regulation N.C. Stroke Care Collaborative listserv Internet Search Calling and ing hospitals Identified Contacts and Participants had many different job titles. Rehabilitation Directors Stroke Coordinators Clinical Management Personnel Conversations with contacts revealed that multiple departments were often contacted to assist in answering questions in the inventory.

8 Hospital Sample

9 Results Overall participation rate was 75% (n= 77). Participating hospitals represented 87.2% of all stroke discharges in % Participation Rate of CARF Hospitals. 96% Participation Rate among Rehabilitation Hospitals or Hospitals with rehabilitation beds. No significant differences between participating and non-participating hospitals with regards to regional location or participation in a health system. Larger hospitals and hospitals with rehabilitation beds were more likely to respond to the inventory.

10 Rehabilitation Settings 83.1% of hospitals offer stroke rehabilitation services (n=64). 67.2% of hospitals offer rehabilitation services in multiple locations (n=43). Rehabilitation Settings Acute Care Home Health Freestanding Acute Inpatient Long Term Acute Care Facility Skilled Nursing Facility (SNF) Post-Acute Care Skilled Inpatient Rehabilitation Unit Outpatient Assisted Living Facility Sub-Acute Facility Community Based Stroke Center Community Based Adult Day Community Based Senior Center

11 Stroke Rehabilitation Therapies Physical Therapy Occupational Therapy Speech and Langauge Pathology Outpatient Therapy Offer/ Offer with Limited Availability Rehabilitation Therapy Recreational Therapy Physiatry Refer Transitional Care Orthodist/Prothetist Stroke Follow-Up Clinic Don't Offer or Refer Child Stroke Specific Music and Art Therapy Percent

12 Stroke Rehabilitation Therapies Therapies Offered 48% of hospitals OFFER 6-8 stroke rehabilitation therapy services 11.2% of hospitals offer therapy services. Therapies Referred 42.3% of hospitals do not refer any therapy services 46.5% of hospitals refer 1-3 therapy services. Physical Therapy is offered by 100% of all hospitals that offer stroke rehabilitation services (n=64).

13 Stroke Rehabilitation Therapies Orthodists/Prothetists are the most likely therapies to be referred (n=24). Other therapies that are offered by hospitals included the following: Aquatic Therapy Audiology Services Pet Therapy Acupuncture and Massage

14 Mental Health Services Psychology or Mental Health Services Psychiatry Offer/ Offer with Limited Availability Refer Neurophysiology Percent Don't Offer or Refer 23.9% of hospitals offer all 3 mental health services. 39.4% of hospitals do not offer mental health services. 59.4% of hospitals do not refer any mental health services for stroke survivors.

15 Mental Health Services Other mental health services offered by hospitals include the following: Behavioral Health TelePsychiatry Licensed Clinical Social Workers Geropsychiatric Unit Inpatient Psychiatric

16 Support Services Nutrition Counseling Patient and Family Interpreter Services Social Services and Chaplaincy Bowel and Bladder Offer/Offer with Limited Availability Refer Medical Wellness Stroke Survivor Caregiver Support Telephone Follow-Up Don't Offer or Refer Medication Vocational Percent

17 Support Services 35. 3% of hospitals offer 6-9 services while 33.8% of hospitals OFFER support services. 71.8% of hospitals do not refer any support services. Hospitals made the following comments about support services: Support Services are available at the Main Hospital in the System. Hospital is in the process of establishing stroke survivor group.

18 Community Services Contractors for Home Remodels Medical Equipment Home Assessments Road Testing Clinical Assessment to Return to Offer/Offer with Limited Availability Refer Community Meals Community Transportation Don't Offer or Refer Percent

19 Community Services Home Assessments are the most likely service to be offered (n=36) while Community Transportation is the next most likely service to be offered (n=34). 71.6% of hospitals OFFER at least 1 community service. 29.6% of hospitals do not offer any community services. 33.8% of hospitals do not refer any community services. 21.1% of hospitals refer 4 services.

20 Telehealth Services 3 hospitals are using telehealth for stroke rehabilitation. 11 additional hospitals are considering using telehealth for stroke rehabilitation. The most common reasons cited for considering using telehealth: Service and tools are already being used in chronic disease management Feasible to extend the available services to stroke rehabilitation.

21 Percent Facility Measures and Scales Severity of Stroke Cognitive Function NIH Stroke Scale Post-Acute Complications Cognitive Function Scales measures mental ability and reasoning NIH Stroke Scale measures the level of impairment after a stroke Post-acute complications 6.6 percent of the hospitals measure deep vein thrombosis (n=6). 6.6 percent of hospitals measure pressure sores (n=6). No other post-acute complication measures were included.

22 Percent Facility Measures and Scales Functional Ability Barthel ADL Index Dysphagia Screen Functional Independence Measures Modified Rankin Scale Patient Falls Quality of Life Barthel ADL measures daily activities that can be performed by a stroke survivor Dysphagia Screen ability to swallow Functional Independent Measures measures cognitive and motor function to determine level of activity that can be completed independently

23 Percent 100 Facility Measures and Scales Functional Ability Barthel ADL Index Dysphagia Screen Functional Independence Measures Modified Rankin Scale Patient Falls Quality of Life Modified Rankin Scale ability to perform daily activities Patient Falls Quality of Life- combination of two Measures SF36 Health Survey health profile that describes overall quality of life. 5% of hospitals use Depression Data and the SF36 Health Survey (n=3) Stroke Specific Quality of Life specifically assesses how the stroke survivor perceives their own quality of life after a stroke 7 % of hospitals use the Stroke Specific Quality of Life Scale (n=4)

24 Percent Facility Measures and Scales Other Measures Discharge Destination Employment Status of Patient Redadmission Data

25 Percent Facility Measures and Scales Specific Discharge Destination Outcomes Home Home with Home Health Assisted Living Inpatient to General Hospital Long Term Care Facility Skilled Nursing Facility Stroke Patient Died

26 Data Linkage 60.6% of hospitals expressed interest in potential rehabilitation data linkage projects (n=43). Factors that could significantly impact the decision to participate in a rehabilitation data linkage project were identified as the following: Administrative Approval Inclusion/Exclusion Guidelines Need to Work with Current Systems Identification of personnel within the hospital with the authority to approve a data linkage project.

27 Limitations to Providing Stroke Services Limitation Percent Insurance Challenges 73.2 Transportation to Treatment 45.1 Patient Compliance 32.4 Family or Social Support 25.4 Accessibility- Location of Treatment 16.9 Staff Education or Experience 14.1 Physician Referral 12.7 Staffing Limitations 11.3 Other Barriers that were listed included the following: The hospital does not provide stroke rehabilitation services. The hospital or facility does not have enough space. Specialized equipment is expensive. The hospital does not receive outpatient referrals from other health care entities.

28 Continuing Education Topics Continuing Education Setting Percent Web Based 76.1 In-Services at Facility 74.6 Regional Conferences 49.3 Conference Calls 39.4 Personal Computer DVD/CD 35.2 State Conferences 26.8 National Conferences 11.3 Other Settings reported included AHEC (regional training centers) and a review of professional papers.

29 Continuing Education Topics Most Common Response was Any Topic (n=3). Acute Treatment Clinical Prevention tpa importance and administration Relationship between stroke type and location and patient symptoms Rehabilitation Physical Therapy and Occupational Therapy Techniques (Neuroplasticity, NDT) Evidence Based Interventions and Technology Rehabilitation Telehealth Sexuality Depression System Increasing Community Resources Preparing for Joint Commission Primary Stroke Center Success Stories

30 Inventory Limitations Inventory Limited to Hospitals Unable to obtain a comprehensive list of Skilled Nursing Facilities. Phone Call with partners revealed that the systems used to identify hospitals were similar to those that would be used to identify Skilled Nursing Facilities. Fax was considered the most common form of communication among Skilled Nursing Facilities and thus an online inventory would not be an effective tool for obtaining the information. Timeline for the inventory and workload required did not make it possible to continue the process to contact 405 Skilled Nursing Facilities.

31 Hospital Systems Inventory Limitations Account for 60% of the hospitals in N.C. There were only 10 hospitals that reported as a system for this inventory. Future inventories should be completed by or for each hospital in a system. Gaps and Limitations of Service 16 Counties do not have a hospital. This inventory revealed the services available and barriers to current care providers. Future inventories need to include hospitals that could not provide a contact.

32 Acknowledgements Anita Holmes, JWTF provided leadership and support. Leigh Hayden, DPH served as preceptor and advisor to the author during the project. Audrey Foster, DPH provided inventory and survey expertise, as well as assisted with data management and inventory deployment. Dr. Samuel Tchwenko, DPH utilized his data analysis skills, knowledge of STATA, and was willing to teach and assist during data reporting and analysis. Paige Bennett, DSHR located and adapted the rehabilitation inventory, assisted with the identification and communication with hospital staff, and provided technical expertise during the entire inventory process. Dr. Kelly Rulison, UNCG provided technical assistance with the inventory revisions and data reporting phases.

33 References American Heart Association & American Stroke Association. Get with the guidelines- Stroke. documents/downloadable/ucm_ pdf. Updated October Accessed on May 20, 2013 Go, A.S., Mozaffarian, D., Roger, V.L., Benjamin, E.J., Berry, J.D., Borden, W.B., Turner, M.B. (2013). Heart disease and stroke statistics 2013 update: A report from the American Heart Association. Circulation, 126(1), e doi: / CIR.0b013e ad Hedworth A, & Brikshavana D. Stroke rehabilitation in the great lakes region. Chicago, IL; June Miller EL, Muray L, Richards L, et al. Comprehensive overview of nursing and interdisciplinary rehabilitation care of the stroke patient: A scientific statement from the american heart association. Stroke. 2012;41: North Carolina Division of Health Service Regulation. Hospitals licensed by the state of north carolina. Raleigh, N.C.: N.C. Department of Health and Human Services; Retrieved from: North Carolina State Center for Health Statistics stroke discharge rates-provisional. Unpublished data file. Accessed on April 16, North Carolina State Center for Health Statistics (NC-SCHS) BRFSS survey results: North carolina counties and AHEC regions. stroke2.html. Updated Retrieved on April 5, North Carolina State Center for Health Statistics (NC-SCHS). North carolina medicaid costs for cardiovascular disease. paid medicaid claims North Carolina Stroke Advisory Council (SAC). Association of state and territorial health officials (ASTHO): Stroke system of care plan for north carolina December Raleigh, N.C.; N.C. Department of Health and Human Services; Tchwenko SN. Burden of cardiovascular disease in north carolina September, Raleigh, N.C.: N.C. Department of Health and Human Services; Retrieved from:

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