An Economic Model for Stroke Rehabilitation in Ontario: Mapping Resource Availability and Patient Needs

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1 An Economic Model for Stroke Rehabilitation in Ontario: Mapping Resource Availability and Patient Needs Matthew J. Meyer, Shelialah Pereira, Andrew McClure, Norine Foley, Katherine Salter, Deborah Willems, Ruth Hall, Eriola Asllani, Jiming Fang, Mark Speechley, Robert Teasell 1

2 Table of Contents Executive Summary... 3 Introduction... 7 Project Overview... 9 Statement of Assumption... 9 Ethical Considerations [1] Identifying Rehabilitation Resources for Stroke in Ontario Introduction Methodology Results Inpatient Rehabilitation Outpatient Rehabilitation Community-Based Rehabilitation Discussion Inpatient Rehabilitation Outpatient Rehabilitation CCAC Rehabilitation [2] Assessing the Accessibility of Inpatient Stroke Rehabilitation in Ontario Introduction Methodology Results Discussion [3] Testing the Association between Resource Availability and Rehabilitation Accessibility Introduction Methodology Results Discussion [4] An Economic Model for Stroke Rehabilitation in Ontario Introduction Methods Results Discussion Project Summary Appendix A Inpatient rehabilitation facility survey Appendix B Outpatient rehabilitation program survey Appendix C CCAC rehabilitation survey

3 Executive Summary This project was designed to assess the availability of post-stroke rehabilitation resources across Ontario, to begin to identify the impact that these resources have on the accessibility of inpatient rehabilitation, and to identify where future investment may be likely to have the greatest impact. All assessments were performed at the level of the Local Health Integration Network (LHIN). The study included 4 separate phases: [1] Information was first collected to assess the rehabilitation resources available to stroke patients in each LHIN [2] Patient information was then used to develop a model to predict what patients are likely to be admitted to inpatient rehabilitation and the model was used to evaluate how accessible inpatient rehabilitation was for stroke patients in each LHIN during 2008/09 [3] Information from the first two phases was used to identify the relationship between rehabilitation resources and inpatient rehabilitation accessibility [4] An economic assessment was performed to identify the investments that would be necessary to improve accessibility to inpatient rehabilitation, as well as identify LHINs that may require future investment in inpatient, outpatient, and CCAC rehabilitation Inpatient Rehabilitation Most facilities reported that limited rehabilitation resources hindered their ability to provide adequate rehabilitation to stroke patients Physiotherapy and Occupational therapy are the most uniformly available services in Ontario, while speech language pathology, social work, recreation therapy, and PT, OT and CD assistant services are more sporadically employed Very few facilities documented the amount of therapy provided to patients making estimation of actual therapy provision challenging Resources for inpatient rehabilitation of stroke patients in Ontario appear to be on the rise, as indicated by reports of more rehabilitation facilities being opened and greater capacity for rehabilitation within current facilities 3

4 Outpatient Rehabilitation No centralized database or routine data collection procedure exists for outpatient rehabilitation making data collection very challenging The majority of facilities were not able to provide information about the number of patients seen, the number of stroke patients seen, or the number of rehabilitation sessions provided More than 60% of outpatient rehabilitation programs reported undergoing changes now or in the near future Since 2009/10, 8 outpatient programs have closed and only 2 have opened in the same time period Survey respondents continually noted that outpatient rehabilitation resources in Ontario were insufficient; including a gap in the North West LHIN where no outpatient rehabilitation is available at all CCAC Rehabilitation CCACs do not have stroke-specific information readily available The number of total rehabilitation visits per stroke patient varied dramatically between regions suggesting differences in service availability Most CCACs reported a wait list for non-urgent rehabilitation services that ranged from one month to nearly a year Only 2 of the responding CCACs reported offering some form of stroke-specific community-based rehabilitation 4

5 Assessing the Accessibility of Inpatient Rehabilitation Our model suggests that characteristics of patients in acute care can be used to predict discharge to inpatient rehabilitation with 83% accuracy We developed two statistics to measure accessibility to post-stroke inpatient rehabilitation: a ratio of observed to expected admissions to inpatient rehabilitation and a count of reasonable candidates not admitted to inpatient rehabilitation. The Champlain, Erie St. Clair, North West and North East LHINs appear to have the highest levels of accessibility to inpatient rehabilitation in Ontario based on our 2 measures Based on the same two measures, the North Simcoe Muskoka, South West, Waterloo Wellington, and Hamilton-Niagara-Haldimand-Brant LHINs appear to have the poorest levels of accessibility Assessing the Relationship between Rehabilitation Resources and Accessibility Although limited information inhibits our ability to draw definitive conclusions, several interesting associations between resources and accessibility were noted More rehabilitation bed days available to stroke patients in a given LHIN appears to be associated with greater accessibility to inpatient rehabilitation Based on facility-level resource information, LHINs with greater accessibility to inpatient rehabilitation also appear to have more outpatient rehabilitation resources Based on the best available CCAC rehabilitation information, LHINs with greater access to inpatient rehabilitation also appear to have poorer access to CCAC rehabilitation resources 5

6 Economic Assessment Estimates suggest that 326 individuals with stroke who could be identified as potentially good rehabilitation candidates were unable to access inpatient rehabilitation in 2009/10 A minimum investment of $7,139,991 is recommended to help improve accessibility Recommended investment in inpatient rehabilitation across LHINs range from approximately $233,000 to $1,150,000 The Central, North West, North Simcoe Muskoka, Central East and Waterloo Wellington LHINs appear to have the greatest need for investment in inpatient rehabilitation The Central, Central East, South West, Mississauga-Halton, and Erie St. Clair LHINs appear to have the greatest need for investment in outpatient rehabilitation The North West, Toronto Central, Champlain, South East and Central East LHINs appear to have the greatest need for investment in CCAC rehabilitation services Further research is necessary to identify the potential benefits of increased investment in rehabilitation resources (ie. reductions in ALC bed days and LTC admissions) 6

7 An Economic Model for Stroke Rehabilitation in Ontario: Mapping Resource Availability and Patient Needs Introduction There is an abundance of evidence to suggest that post-acute rehabilitation contributes to patient recovery after stroke 1. Yet, providing this rehabilitation is a complex process that can include everything from 24-hour care in an inpatient rehabilitation facility to occasional support in the community. To meet this demand, an efficient and effective stroke rehabilitation system must incorporate a wide diversity of rehabilitation services across the continuum, and evaluating such a system necessitates an equally broad perspective. In Ontario, three general forms of government-funded rehabilitation have been made available to stroke patients: inpatient rehabilitation (IPR), outpatient rehabilitation (OPR), and communitybased rehabilitation (C-BR) (figure 1). Yet, deciding where and to whom these services should be offered has presented a significant challenge for both stroke rehabilitation providers and the decision makers who allocate funding 2. In Ontario, there are 14 Local Health Integration Networks (LHINs) that coordinate regional care (figure 2), and each face different challenges. Regional populations vary in density, demographics and geographic distribution. Accordingly, health care providers and decision makers have evolved slightly different strategies for providing rehabilitation to stroke patients. Figure 1. Schematic diagram of patient flow through Ontario s stroke rehabilitation system Acute Stroke ER/Acute Care Inpatient Rehabilitation Outpatient /Day Hospital Rehabilitation Community Based Rehabilitation 7

8 Figure 2. A map of Ontario s Local Health Integration Networks (LHIN) 3. Although individually-tailored regional programs for stroke rehabilitation are necessary, they make evaluation of Ontario s stroke rehabilitation system difficult. For instance, individuals who experience stroke in Ontario may receive their inpatient rehabilitation in a stroke-dedicated service, neurological rehabilitation unit, or general rehabilitation unit depending on where they live. This diversity of services provides a challenge when trying to quantify what resources are available to stroke patients. As patients progress through the system, this difficulty is magnified. When stroke patients begin to access outpatient and community-based rehabilitation programs, more attention is placed on the patient s needs and less on what precipitated their need for services. While this shift in thinking and emphasis on personalized program development is likely in the patient s best interest, it makes retrospective patient identification in administrative databases nearly impossible. While these limitations have hindered previous assessment of rehabilitation resources in Ontario, some measure of resource availability is critical for stroke system evaluation. The resources available to care for stroke patients in a given region may dictate patients ability to access the care they need, and this is true along the entire continuum of care. If patients are readily able to access inpatient rehabilitation, this can help relieve some of the burden placed on acute hospitals and reduce the number of alternate level of care (ALC) bed days occupied by stroke patients 4. However, readily accessible inpatient rehabilitation equally depends on the accessibility of outpatient and community-based rehabilitation. 8

9 There remains no consensus regarding what proportion of stroke patients require post-stroke rehabilitation. However, only the needs of a patient should dictate whether or not they receive rehabilitation, not the region in which they live. As described by the Canada Health Act, all Canadians should have equitable access to healthcare services. When it comes to stroke rehabilitation, this means that similar patients should have the same opportunity to access rehabilitation regardless of where they live. The purpose of this study was to evaluate the availability of rehabilitation resources in Ontario to individuals with stroke, to assess the impact that resource availability has on regional accessibility to inpatient rehabilitation, and to identify regions where future investment in all forms of rehabilitation may have the greatest potential to improve patient care. Project Overview This project comprised four phases: [1] Information from databases at the Institute for Clinical Evaluative Sciences (ICES) and an Ontario-wide survey of rehabilitation facilities was used to identify rehabilitation resources that were available to stroke patients in fiscal year 2009/10 (April 1, 2009 March 31, 2010). [2] A method was developed to assess the regional accessibility of post-stroke inpatient rehabilitation in Ontario. [3] The relationship between rehabilitation resource availability and the accessibility of inpatient rehabilitation was tested. [4] An economic assessment was performed to identify regions where future investment in stroke rehabilitation would likely have the greatest impact. Statement of Assumption Efforts were made to obtain the most accurate and most recent information for each phase of this study. Unfortunately, information from the same year was not available for much of the necessary data. Therefore, it was assumed, for the purposes of this report, that rehabilitation 9

10 resource availability and accessibility has remained relatively constant in Ontario between 2007/08 and 2009/10. Ethical Considerations A full research proposal was submitted to the ethics department at the University of Western Ontario. As no patient-level information would be seen by any member of our research team outside of the analysts at the Institute for Clinical Evaluative Sciences (ICES) and only regional summary level information would be presented in the final report, the reviewing ethics officer deemed that the proposal did not require full review and could proceed as planned. The study was conducted with the utmost respect for patient privacy and all data acquisition procedures adhered to the strict ethical requirements mandated by ICES. [1] Identifying Rehabilitation Resources for Stroke in Ontario Introduction It has been suggested that the provision of stroke rehabilitation can be divided into three components: structure (basic resources), process (the provision of services) and outcome 5. Of these three, it is structure that lays the groundwork for rehabilitation. Although arguably not the most important component of care, without the structure of facilities, equipment and staff, rehabilitation of stroke patients would not be possible. Adding to its importance, the structure of care is also a factor that is relatively easy to modify. It is often much easier to open a new unit or hire a new staff member than it is to alter clinical practice or improve patient outcomes. In Ontario, government funding for rehabilitation is provided to the LHINs who, in turn, allocate resources to regional facilities. These facilities divide funds among their rehabilitation programs as they see fit. Therefore, decisions regarding the allocation of funding to stroke rehabilitation are made by local facilities based on the perceived need for stroke rehabilitation relative to other services. Some facilities choose to develop stroke-specific programs while others do not. This funding system has traditionally made it very difficult to assess what resources are allocated directly to the rehabilitation of stroke patients. 10

11 In 2000, the Canadian Institute for Health Information (CIHI) implemented the National Rehabilitation Reporting System (NRS) to begin collecting data from inpatient rehabilitation facilities across Canada and in 2002, the Ontario Ministry of Health and Long-Term Care (MOHLTC) mandated that all facilities with designated inpatient rehabilitation beds report to the NRS 6. As such, a comprehensive list of inpatient rehabilitation facilities in Ontario is now available along with information about the number of stroke patients admitted to these facilities and the number of days of rehabilitation provided to them. The Ministry of Health has since established a similar database for community services called the Home Care Database (HCD). This information was obtained from the Institute for Clinical Evaluative Sciences (ICES) 7. Unfortunately, no such database currently exists for outpatient rehabilitation services. The NRS and HCRS represent an important tool with which to begin to quantify rehabilitation resources in Ontario. Data elements such as the rehabilitation bed days consumed by stroke patients give an estimate of the availability of regional services, while the comprehensive list of inpatient rehabilitation facilities provides contacts for further inquiry into service provision. The purpose of this first phase of our study was to compile information from available databases and supplement this information with a survey of all facilities that provided government-funded inpatient, outpatient and community-based rehabilitation across Ontario in fiscal year 2009/10. Methodology ICES Data Retrieval A member of our research team at the Institute for Clinical Evaluative Sciences (ICES) coordinated access to data from the NRS and HCRS as necessary for fiscal year 2009/10. Due to the extensive infrastructure and data quality initiatives adopted by ICES, data drawn from these databases pertaining to stroke rehabilitation resource availability was considered to be the gold standard and was used whenever possible. Information drawn from the NRS included the number of inpatient rehabilitation facilities and total inpatient rehabilitation bed days consumed by stroke patients. Information drawn from the HCRS included the number of stroke patients accessing community rehabilitation services within 60 days of acute discharge and the average number of rehabilitation visits per patient. 11

12 Survey Development In an attempt to supplement available CIHI data, three separate surveys were developed; one each for inpatient, outpatient and community-based rehabilitation providers (Appendices A-C). Input from regional members of the Ontario Stroke Strategy (OSS) was sought to identify pertinent information that should be included in the survey. Surveys were then developed under the guidance of an expert in the department of Epidemiology and Biostatistics at the University of Western Ontario. Surveys were designed to be performed over the telephone and targeted managers or coordinator of inpatient and outpatient rehabilitation units and directors of client services for regional Community Care Access Centres (CCAC). Trial surveys were conducted with the local rehabilitation coordinator at Parkwood Hospital and the director of client services for the Southwestern Ontario CCAC to test the feasibility of obtaining responses. Changes to survey questions were made as necessary. Survey Methodology A list of all facilities who reported providing inpatient rehabilitation to stroke patients in fiscal year 2009/10 according to the NRS was retrieved from ICES. All facilities on the list were contacted by telephone to identify any unit in which a stroke patient may have received inpatient rehabilitation. For each such unit, the contact information of the manager or coordinator was retrieved to generate a province-wide list. Beginning in April 2010, a member of our research team began attempting to contact all persons on the list, via telephone or , to arrange a time to conduct the survey. Managers were also provided the option of returning the survey via if they preferred. Information regarding the types of units providing inpatient rehabilitation and the number of beds was not available in the NRS. Therefore, facilities were asked in the survey about the availability of rehabilitation beds and the type of rehabilitation provided. To try to simplify responses, respondents were asked about three types of inpatient rehabilitation: short-stay, slow-stream, and standard. Short stay was defined as any short-term rehabilitation bed where a maximum length of stay was applied (usually 14 days or less). Slow-stream rehabilitation was defined as a rehabilitation bed where patients received less intense rehabilitation over a longer period of time (this included low-tolerance long-duration (LTLD) rehabilitation units). Finally, 12

13 standard rehabilitation referred to units where traditional high-intensity post-stroke rehabilitation took place with no official restriction on length of stay. Additional questions pertained to the staffing levels available to provide inpatient rehabilitation in the identified units. Respondents were asked about the number of funded FTEs for several rehabilitation specializations on each unit where rehabilitation took place. Estimates were accepted and noted as such. In instances where staff split time between several units, the respondent was asked about the proportion of time spent in each unit. If this proportion was not available or could not be estimated, the FTE was divided equally between units. Calculations pertaining to staffing levels across the entire LHIN were performed only for short-stay and standard rehabilitation beds. Respondents were also asked several more descriptive questions regarding the provision of rehabilitation at their facility, challenges they face and anticipated changes. Responses to these questions are summarized in general terms and key findings reported. At the time of initial contact during the inpatient rehabilitation survey, facilities were asked about the availability of on-site outpatient rehabilitation services. Managers of inpatient rehabilitation facilities were also asked if they referred patients to an outpatient program and if they could provide a contact. Finally, regional stroke coordinators from the Ontario Stroke Network were contacted and an internet search was performed to find previously unidentified facilities that provided government-funded outpatient rehabilitation to stroke patients in 2009/10. A provincewide list was generated and beginning in May 2010, outpatient rehabilitation facilities were contacted via telephone or . Outpatient managers were asked about all outpatient rehabilitation programs in which a stroke patient may have been admitted in fiscal year 2009/10. As no database for outpatient rehabilitation services currently exists, surveyed facilities were asked to provide values or estimates, if possible, of the total number of patients and stroke patients provided rehabilitation as well as the number of total rehabilitation sessions provided to stroke patients. Respondents were also asked about the number of FTEs for rehabilitation staff available in these programs and a number of descriptive questions similar to those included in the inpatient rehabilitation survey. 13

14 Finally, a list of directors of client services from each LHIN was obtained via direct contact with the regional CCAC office in each LHIN. Information pertaining to the number of stroke patients able to access community-rehabilitation services was provided by ICES. Beginning in September 2010, contact was initiated with each coordinator and surveys were conducted. Surveys were designed to allow coordinators to provide descriptive information about regional services and to comment on programs that may be specifically designed for stroke patients. Data Compilation All information was summarized at the LHIN level. For each of the 14 LHINs, information from all facilities was combined to represent the regional rehabilitation resources available to stroke patients. Results were divided into two sections. Structural results include detailed numeric information related to the availability of resources in each LHIN and include both CIHI data and survey results as appropriate. Responses to descriptive questions formed the second section and are presented separately. In order to deal with the diverse structures of rehabilitation available across the province, surveys were designed to identify the proportion of regional rehabilitation services that had been consumed by stroke patients. As most facilities reported operating at, or near, full capacity, the resources provided to stroke patients in FY 2009/10 (eg. bed days) were assumed to represent an estimate of the resources available to stroke patients during that year. This assumption allowed for comparison of stroke-specific resource availability between regions regardless of whether or not rehabilitation was provided in a stroke-dedicated or general facility. However, information about the availability of stroke-specific programs was also collected. Information regarding resource availability was requested at the most finite possible level. Facilities were asked about the number of beds or sessions available to stroke patients and the staff available to provide care. As the purpose of this project was to assess regional capacity for provision of stroke rehabilitation, information from facilities that only cared for stroke patients periodically (fewer than 5 stroke patients annually) were removed from analyses. However the number of such facilities was noted. Whenever possible, results are presented as estimates of total regional resources as well as weighted averages. 14

15 Results Inpatient Rehabilitation Survey Response Rate A total of 74 facilities were identified as having provided inpatient rehabilitation to stroke patients between 2007 and Sixteen facilities reported that they did not provide post-acute inpatient rehabilitation to stroke patients in fiscal year 2009/10. Four facilities reported that they had cared for fewer than 5 stroke patients and were removed from analyses. Fifty-four facilities remained and each was provided with the survey to complete over the telephone or via . Fifty-two facilities completed the survey and two have not responded. Structural Results A detailed summary of structural results are provided in tables 1-3. Information was drawn from ICES databases whenever possible and supplemented with survey results when necessary. In total, 54 facilities were identified that provided post-acute inpatient rehabilitation to more than 5 stroke patients in fiscal year 2009/10. Within these facilities, 84 units where stroke patients had received rehabilitation were identified. Table 1. The number of facilities and units providing inpatient rehabilitation to stroke patients by LHIN, the number of inpatient rehabilitation bed days occupied by stroke patients, and the ratio of bed days to living stroke discharges from an acute hospital in FY 2009/10. LHIN Facilities 1 Units 2 Inpatient Rehabilitation Bed Days 3 Inpatient Rehabilitation Bed Days per Stroke Discharge 4 (1) Erie St. Clair 3 3* 7, (2)South West 5 5 9, (3)Waterloo Wellington 2 6 5, (4) Hamilton Niagara Haldimand Brant (5)Central West 2 3 1, (6) Mississauga Halton 3 9 8, (7) Toronto Central , (8) Central 4 4 6, (9) Central East 7 8* 10, (10) South East 4 6 5, (11) Champlain 6 9 9, (12) North Simcoe Muskoka 2 3 2,

16 (13) North East , (14) North West 1 3 4, Total , The number of facilities providing inpatient rehabilitation to stroke patients in FY 2009/10 2 The number of units providing inpatient rehabilitation to stroke patients in FY 2009/10 3 Estimate derived from the upcoming 2011 Ontario Stroke Evaluation Technical Report 7. (mean LOS x number of stroke admissions) 4 Estimate derived from the upcoming 2011 Ontario Stroke Evaluation Technical Report 7. (Estimate of bed days/ unique patients discharged from an acute facility after stroke in 2009/10) Missing information, 1 per LHIN * Estimate derived from available information Very few facilities reported having beds reserved for short-stay rehabilitation (ie. beds available only for a designated length of stay, usually less than 14 days). Of the four LHINs where shortstay rehabilitation beds were available, only Central East had short stay beds designated for stroke patients. Across the province, 21 facilities reported providing slow-stream rehabilitation to stroke patients. Many of the respondents suggested that they felt this was an important component of the rehabilitation system and a number of different means were employed to be able to provide this care to patients. Some facilities reported development of a designated slow-stream or lowtolerance long-duration (LTLD) rehabilitation unit, while others used available complex continuing care (CCC) beds to provide extended rehabilitation to suitable patients. Information pertaining to CCC beds was only included in instances where these beds were specifically used to care for patients who required extended low-tolerance rehabilitation to attain their rehabilitation goals. Some form of slow-stream rehabilitation was available in nearly every LHIN; however, only two LHINs had slow-stream rehabilitation beds dedicated to stroke patients. The majority of facilities reported providing standard rehabilitation to stroke patients. Six of the fourteen LHINs provided stroke-dedicated rehabilitation, while two employed neurological rehabilitation units that were not technically dedicated to stroke rehabilitation, but whose patient population was almost entirely composed of stroke patients. Table 2. Survey results from all hospitals in Ontario that provided inpatient rehabilitation to >5 stroke patients in 2009/10 for the number of short stay, slow stream and standard rehabilitation beds available to and dedicated to stroke patients by LHIN LHIN Rehabilitation Facilities and Beds Available to Stroke Patients Short-stay Slow-stream/ CCC Standard 16

17 # 1 Beds 2 Stroke 3 # 1 Beds 2 Stroke 3 # 1 Beds 2 Stroke 3 (1) Erie St. Clair 0* NA* NA* 0* NA* NA* 2* 43* 20 (2)South West 0 NA NA (3)Waterloo Wellington 2 UD (4) Hamilton Niagara Haldimand Brant 0 NA NA (5)Central West 0 NA NA (6) Mississauga Halton 0 NA NA (7) Toronto Central 0 NA NA * (8) Central 0 NA NA (9) Central East * 62* 0* (10) South East 0 NA NA (11) Champlain (12) North Simcoe Muskoka 0 NA NA (13) North East * 0 (14) North West 0 NA NA The number of facilities in which the denoted form of rehabilitation was available to stroke patients in 2 The total number of rehabilitation beds of the denoted form within all identified units 3 The number of rehabilitation beds of the denoted form held exclusively for stroke patients CCC beds were included only in cases where the survey respondent indicated that these beds were used to provide extended rehabilitation Missing information (maximum 1 facility per LHIN) Not designated, but stroke patients are given high priority * Estimate derived from available information NA Not applicable. UD no defined number of beds (care is provided on an as-needed basis) In order to assess regional rehabilitation resource availability, facilities were asked about staffing levels for 7 rehabilitation professions. Estimated staffing levels are provided as a ratio of rehabilitation beds per FTE for each profession to reflect the average case-load experienced by rehabilitation staff across each region (Table 3). Only facilities for which complete bed and FTE information was available were used in the calculations. Since the availability of slowstream rehabilitation varied dramatically across the province and the intensity of therapy on these units is much lower than in standard rehabilitation, only short-term and standard rehabilitation beds were considered in the calculation of beds per FTE. Table 3. Results from survey of managers and coordinators of inpatient rehabilitation units in Ontario during fiscal year 2009/10; summary of average staffing caseload on units providing rehabilitation to stroke patients LHIN Number of rehabilitation beds per FTE 1 LHIN total (range) PT OT SLP SW PT/OT assistant CDA Rec. therapist 17

18 (1) Erie St. Clair 9.6 ( ) (2) South West 8.2* ( ) (3) Waterloo 10.9 Wellington ( ) (4) Hamilton Niagara 9.4* Haldimand Brant ( ) (5) Central West 10.0 (10.0) (6)Mississauga 9.2* Halton ( ) (7) Toronto Central 8.9 ( ) (8) Central 13.8* (8.7-20) (9) Central East 11.3* ( ) (10) South East 13.9 ( ) (11) Champlain 6.7 ( ) (12) North Simcoe 10.2 Muskoka ( ) (13) North East 10.1* ( ) 11.6 ( ) 8.9* ( ) 11.8 ( ) 10.1* ( ) 12.3 (12.3) 10.8* ( ) 9.0 ( ) 18.0* ( ) 13.2* ( ) 15 ( ) 8.2 ( ) 14.0 ( ) 10.7* ( ) 16.5 ( ) 18.2* ( ) 60.0 ( ) 30.3* ( ) 32.0 (32.0) 39.0* ( ) 15.8 ( ) 46.8* ( ) 34.4* ( ) 35.4 ( ) 25.3 ( ) 37.5 ( ) 13.8* ( ) 21.5 ( ) 16.3* ( ) 75.0 ( ) 28.1* ( ) 64.0 (64.0) 21.4* ( ) * ( ) 32* ( ) 125 (76.7) 21.8 ( ) 27.3 ( ) 16.7* ( ) 12.3 ( ) 10.8* ( ) 12.2 ( ) 10.8* ( ) 9.7 (9.7) 16.5* ( ) 15.2 ( ) 24.1* ( ) 13.1* ( ) 18.8 ( ) 14 ( ) 13 ( ) 12.8* ( ) (57.5) NA (NA) (66.0) (23.3) 64.0 (64.0) 115.3* ( ) ( ) 222.5* (75.0) NA* (NA) NA (NA) NA (NA) NA (NA) 71.9* (29.8) 39.1 ( ) 28.8* ( ) 66.7 ( ) 50.7* ( ) 32.0 (32.0) 37.3* ( ) ( ) NA* (NA) 60.6* ( ) ( ) ( ) NA (NA) 29.1* ( ) (14) North West NA ( ) ( ) ( ) ( ) ( ) (NA) (40.0) 1 Includes all short-stay and longer duration rehabilitation beds (excludes slow-stream and CCC) Inpatient rehabilitation provided by a single facility Missing information (maximum 1 facility per LHIN) NA Service not provided by any inpatient rehabilitation facilities * Estimate derived from available information Most facilities appeared to focus on provision of physiotherapy and occupational therapy and, as such, the ratios of beds to FTEs in these professions did not vary dramatically. The exception was in the North West where only one rehabilitation facility was available and the therapist caseload was more than double what is seen elsewhere. Many facilities reported that speech language pathology was more difficult to provide than PT and OT. This was reflected in much higher bed-to-fte ratios and wider ranges. However, facilities also noted that not all patients require the care of an SLP and, therefore, therapists are often shared between units. Social workers were similarly employed in all regions and at most facilities, but often split their time between units or were responsible for a large number of rehabilitation beds. 18

19 Most facilities across the province reported employing a PT, OT, or combined assistant to help with rehabilitation provision. The number of beds for which assistants provided supplemental therapy was often slightly higher than the number of beds for which local PTs or OTs were responsible. Communicative disorders assistants (CDAs) were much less frequently employed if at all. Only 8 LHINs had facilities with a CDA and the bed-to-fte ratios by LHIN were therefore extremely high. Finally, recreation therapists were available in many units across the province, but were often reported to be split between units and to provide much of their service in group settings. Descriptive Results In addition to quantitative information, the inpatient rehabilitation survey also included 6 questions that targeted more general responses. Summary results are provided for each survey question individually. I. For each of the following, approximately how many hours of therapy a day were provided to appropriate stroke patients? Physical therapy (PT), Occupational therapy (OT), Speech language therapy (SLT), Social work (SW))? Of the 54 facilities surveyed, only two reported an officially documented number of hours of therapy provided to patients. The facility reported that patients received 127 minutes of PT and minutes of OT per week. The other reported an average of 115 minutes of independent PT and OT a week plus additional group therapy sessions. All other facilities reported an estimated average that ranged from 20 minutes to 4 hours a day. Without exception, facilities reported higher estimates for PT and OT compared to SLT. On 17 rehabilitation units, the survey respondent reported that there was no speech language pathologist regularly available and that SLT was only offered as needed on a consult basis. II. At your facility are therapists replaced when they are away (sick or on vacation)? Out of 71 rehabilitation units that responded to this question only 32 (45%) reported having access to resources to cover therapists when they were away sick, while only 20 (28%) indicated that they were successful in replacing therapists more than 80% of the time. The best rates of replacement were noted in the North West and Champlain LHINs, while across all of the 19

20 Erie-St. Clair, South West, Waterloo-Wellington, and Hamilton-Niagara-Haldimand-Brant LHINs, only a single facility reported being able to cover therapists when they were sick and even this facility suggested that they were only able to cover therapists 25% of the time. Coverage rates for holidays and extended sick leaves was only slightly better with 40 of the 71 units (56%) reporting access to adequate resources for therapist replacement under these circumstances. III. Do you provide weekend therapy at your facility? Out of 72 units that responded to this question, 17 (24%) reported availability of some weekend therapy. Of these facilities, 3 offered only PT on weekends, 1 offered PT and OT, 6 reported only therapy provided by aides or other support workers, and 4 facilities offered weekend therapy to high priority patients only. Only the 3 remaining units (4%) reported provision of weekend therapy with no cited restrictions. IV. Given current resources, could you provide rehabilitation to more stroke patients annually? Out of the 82 units that responded to this question, 16 indicated that they had the capacity to provide more rehabilitation to stroke patients without sacrificing provision of rehabilitation to other patients. The majority of these facilities noted that they were near full capacity most of the time, but had occasional periods of lower occupancy that could be improved. V. In 2010 or 2011, do you anticipate any changes that may affect the way that you provide post-acute rehabilitation to stroke patients? (ie. staffing changes, adding/removing beds)? Of the 54 facilities contacted, 17 reported no anticipated changes in these two fiscal years. Eighteen facilities reported changes in staffing. Ten had, or were planning on, adding additional staff to their units, while 5 reported decreasing the level of staffing. Three facilities were rearranging their staffing model. One of these facilities was replacing a PT and an OT with 2 therapist aides, while two were replacing registered nurses (RN) with registered practical nurses (RPN). Thirteen facilities were anticipating changes in the therapy they would be providing to stroke patients. Nine indicated that they would be increasing the amount of therapy available to patients including 4 that were considering addition of weekend therapy. Three facilities 20

21 anticipated shifts in their therapy provision model, but suggested the quantity of therapy would not change. Only a single facility noted potential reductions in the amount of therapy they would be able to provide. Finally, 15 facilities reported changes in the structure of their rehabilitation units. Five facilities were re-arranging the existing model for service provision, but anticipated no overall difference in their capacity for care, while 3 units reported expanding current units and 1 facility planned on reducing the size of its unit. Two facilities reported adding a brand-new rehabilitation unit and two facilities were developing a stroke-dedicated rehabilitation unit. Three units noted that their rehabilitation program was currently under review and anticipated changes in the near future. VI. Is there any information about the resources available to you for provision of stroke rehabilitation that has not been covered by this survey? In total, 22 respondents provided answers to this question and offered discussion that generally focused on three key areas: additional staff, regional networking, and resource limitations. Seven facilities reported the use of professionals not mentioned by the survey. Included in this list were two facilities that reported employing dieticians, and one facility each who reported a horticultural therapist, discharge coordinator, personal support worker and spiritual care associate. Four facilities commented on networking opportunities between facilities. Two facilities in the GTA made mention of their involvement in the GTA or West GTA rehabilitation networks and indicated that this enhanced their ability to provide quality care. The other two facilities, one in Central East and one in Central West noted they received very little support from regional hospitals or networks and this hindered their ability to provide care. Finally, three facilities reported limited resource availability as a challenge to providing good rehabilitative care post stroke. The first respondent noted that in the Central LHIN, outpatient and CCAC neuro-rehabilitation resources were insufficient, especially in the northern sections of the LHIN, and that this contributed to longer lengths of stay in inpatient rehabilitation. The other two respondents, from the Central East and Champlain LHINs, suggested that small rural hospitals had difficulty accessing specialty services for stroke patients and that this made it very difficult to provide evidence-based care. 21

22 Outpatient Rehabilitation There are currently no centralized databases that collect information from outpatient rehabilitation facilities in Ontario. Therefore, all information regarding outpatient rehabilitation was collected during the province-wide outpatient rehabilitation survey. The results of the survey are summarized in tables 4-6. Survey Response Rate In total, 76 facilities were identified as having provided outpatient rehabilitation to stroke patients in 2009/10. Of these, 2 have since closed and no one could be contacted to collect information. Of the remaining 74 facilities, 25 reported caring for fewer than 5 stroke patients during that time and were not asked to complete the full survey. These 25 facilities were generally small rural hospitals that were able to provide rehabilitation to the occasional local stroke patient when necessary. The vast majority of these hospitals were located in the Northern regions of the province. Of the 49 remaining larger volume facilities, 42 completed the survey. Structural Results Thirteen of the facilities that provided rehabilitation to more than 5 stroke patients annually did so in more than 1 program, resulting in 62 outpatient rehabilitation programs that accepted stroke patients in 2009/10. Reasons for multiple programs included separate programs for physiotherapy and occupational therapy, group versus individualized programs, an outpatient rehabilitation program and a day hospital, or multiple outpatient sites within the same umbrella hospital. Table 4. Outpatient rehabilitation survey results for the number of facilities providing outpatient rehabilitation to stroke patients in 2009/10, the number of these that cared for more than 5 stroke patients, and the total number of outpatient rehabilitation programs in higher volume facilities. LHIN Facilities 1 (total) Facilities 2 (>5 stroke pts/yr.) Programs 3 (1) Erie St. Clair 3 3 3* (2)South West (3)Waterloo Wellington 6 2* 4* 22

23 (4) Hamilton Niagara Haldimand Brant (5)Central West (6) Mississauga Halton (7) Toronto Central (8) Central (9) Central East (10) South East (11) Champlain (12) North Simcoe Muskoka (13) North East (14) North West Total All identified facilities that provided outpatient rehabilitation to stroke patients 2 Facilities that provided outpatient rehabilitation to >5 stroke patients 3 Number of outpatient programs available to stroke patients in higher volume facilities Missing information * Estimate derived from available information Facilities were asked about the total number of patients to whom they provided outpatient rehabilitation, the number of stroke patients, and the total number of rehabilitation sessions provided to stroke patients in 2009/10. Few facilities were able to respond to these questions. In total, only 16 of the 42 responding facilities provided answers to each of the three questions and of these, 8 included estimates for at least 1 of the three responses. Therefore, no conclusions could be drawn regarding outpatient rehabilitation resources at the patient level. The most common reasons why facilities could not include this information were that central records were not kept for easy access and that facilities did not have the resources or the time to extract the information from charts. Facilities were also asked about the number of FTEs they had available to provide outpatient rehabilitation in the units that accepted stroke patients. Whenever possible, estimates of the number of total patients per FTE were calculated as well as the number of stroke patients per FTE. The ratios of total patients and stroke patients to FTE are based on the reported number of patients admitted to all programs in each LHIN for which information was available divided by the FTE estimates for those facilities. The numbers, therefore, do not reflect the actual number of patients seen by each FTE in 2009/10, but rather an estimate of total patients per FTE. Due to limited information, estimates of actual case load could not be calculated. Results are presented in tables 5 and 6. 23

24 Table 5. Outpatient rehabilitation survey results for full-time equivalents (FTEs) of physiotherapy (PT), occupational therapy (OT), and speech language pathology (SLP) by LHIN in 2009/10 as total numbers, rehabilitation patients per FTE, and stroke patients per FTE. LHIN PT OT SLP 1 2 FTE 1 Pts/FTE 2 Strokes/ Strokes/ Strokes/ FTE 3 FTE Pts/FTE FTE 3 FTE Pts/FTE FTE 3 (1) Erie St. Clair 6.4 Not av. Not av. 2.5 Not av. Not av. 1.4 Not av. Not av. (2)South West * 201.1* * 281.6* * 541.5* (3)Waterloo * 19.8* * 39.1* * 62.5* Wellington (4) Hamilton Niagara 9.4* * 58.6* 6.9* * 157.4* 3.2* * 306.1* Haldimand Brant (5)Central West 1.0 Not av. Not av. 1.0 Not av. Not av. 0.1 Not av. Not av. (6) Mississauga * 143.0* * 166.7* * 250.0* Halton (7) Toronto Central 7.5* 292.0* 196.0* * 274.0* * 561.0* (8) Central 7.0 Not av. Not av. 3.5 Not av. Not av. 0.6 Not av. Not av. (9) Central East * 19.0* * 82.2* * 323.8* (10) South East * 4.9* * 16.7* * 9.4* (11) Champlain * 30.0* 1.9 Not av. Not av. 1.1 Not av. Not av. (12) North Simcoe * 111.8* * 111.8* * 111.8* Muskoka (13) North East * 3.22* * 16.1* * 16.1* (14) North West * 4.27* * 31.3* * 58.8* 1 The total number of FTEs in the denoted discipline in FY 2009/10 2 The number of rehabilitation patients per FTE in the denoted discipline in FY 2009/10 3 The number of stroke patients per FTE in the denoted discipline in FY 2009/10 Missing facility information * Estimate derived from available information Not av. Data not available Table 6. Outpatient rehabilitation survey results for full-time equivalents (FTEs) of physiotherapy or occupational therapy assistants, and communicative disorders assistants (CDA) by LHIN in 2009/10 as total numbers, rehabilitation patients per FTE, and stroke patients per FTE. LHIN PT/ OT Assistants CDA FTE 1 Pts/FTE 2 Strokes FTE 1 Pts/FTE 2 Strokes /FTE 3 /FTE 3 (1) Erie St. Clair 4.7 Not av. Not av. 0 NA NA (2)South West * 391.1* 0 NA NA (3)Waterloo Wellington * 61* 0.6 not av. not av. (4) Hamilton Niagara Haldimand Brant 7.9* * 157.4* 0.55* 19248* 2204* (5)Central West 0.5 Not av. Not av. 0 NA NA (6) Mississauga Halton * 143* 0 NA NA (7) Toronto Central 2 877* 589* * 785* 24

25 (8) Central 4.5 Not av. Not av. 0 NA NA (9) Central East NA NA (10) South East * 25* 0 NA NA (11) Champlain 4.6 Not av. Not av. 0 NA NA (12) North Simcoe Muskoka * 111.8* 0 NA NA (13) North East 3.2 Not av. Not av. 0 NA NA (14) North West * 9.4* 0 NA NA 1 The total number of FTEs in the denoted discipline in FY 2009/10 2 The number of rehabilitation patients per FTE in the denoted discipline in FY 2009/10 3 The number of stroke patients per FTE in the denoted discipline in FY 2009/10 Missing information * Estimate derived from available information Not av. Data not available Descriptive Results An additional nine descriptive questions were also asked of each outpatient respondent. The results are summarized for each question individually I. Do you hold outpatient rehabilitation spaces for stroke patients? Of 53 programs that responded to this question, only 6 indicated that they held spots specifically for stroke patients. Two of these programs admitted only stroke patients and the other 4 held 1-2 positions for stroke patients each week. II. Do you have any restrictions on where you can accept stroke patients from? A total of 51 programs responded to this question. Twenty programs reported firm restrictions regarding program referrals. Seven programs reported only accepting patients from an affiliated inpatient rehabilitation or acute hospital, while the other 13 only accepted patients from a defined geographic region (usually within the local community or LHIN). Six additional programs reported no firm restrictions, but indicated that certain patients were given higher priority. III. Do you accept patients who need only a single service? 25

26 Of 53 responding programs, 9 indicated that they did not accept patients who required only a single rehabilitation service; 8 of these were day hospital programs. Of the 42 programs that responded positively to this question, two only offered a single service (both only PT). IV. Do you have any admission criteria other than geographic restrictions or number of services required? Fifty-two programs responded to this question and of these, 7 reported no additional admission criteria. A summary of the additional admission criteria mentioned by respondents is presented in table 7 along with the frequency of each response Table 7. Survey responses for admission criteria for outpatient rehabilitation in Ontario and the frequency of each response Admission Criteria Freq Admission Criteria Freq Potential for recovery/ attainable goals 16 Recent stroke 6 Medical stability 11 Community-dwelling 5 Age restrictions 9 Time-limited rehabilitation required 3 Own transportation 9 Rehab not available in community 1 Willing/ able to participate 9 Valid OHIP card 1 Stroke/ neurological diagnosis 8 No behavioural issues 1 Independent (or minimal assist) in toileting 7 Safe 1 V. In 2009/10, was there a wait list for outpatient rehabilitation and, if so, how long was the average wait? Thirty-eight programs responded to this question, of which only 4 reported that they did not have a wait list for access to outpatient rehabilitation in 2009/10. Of those programs with wait lists, estimated average wait times ranged from 2 weeks to 3 months. Several programs reported that wait lists for PT were shorter than those for OT and that access to SLP often required the longest wait. Interestingly, one respondent noted that although they had attempted to reduce wait times to zero, patients often cancelled appointments made in the first 7 days after acute discharge. This respondent noted that they found a wait list time of 7 days was ideal. VI. Given current resources, could you provide outpatient rehabilitation to a greater number of stroke patients? 26

27 Fifteen of 51 programs reported that they could provide rehabilitation to a greater number of stroke patients annually. One of these programs indicated that they could provide only more PT, but that OT resources were fully employed. Another respondent noted that their outpatient rehabilitation is dependent on their inpatient program, because therapists are shared between the two, and that if inpatient rehabilitation slowed, more space would become available in outpatient rehabilitation. Four respondents indicated that they were not sure if they could provide more care to stroke patients. VII. How long is an average rehabilitation session? The vast majority of respondents indicated that sessions were generally between 30 minutes and one hour per service depending on patient need and tolerance. Several programs reported 20 minute sessions for some therapies and one indicated that they offered a half-day program that incorporated numerous activities. VIII. Do you anticipate any changes in the above information in 2010 or 2011? Survey responses suggest that there were significant changes taking place in outpatient rehabilitation. Thirty-three programs indicated that they had experienced or were expecting changes in 2010 or Fifteen facilities reported a decrease in services including 8 programs that had been closed since However, 11 facilities reported an increase in services, 2 of which were opening a new program. Five facilities indicated that they would be making structural changes that would not impact the level of service available and 4 programs noted that they were currently under review and do not know what the outcome will be. IX. Is there any other information about outpatient stroke rehabilitation at your facility that you feel we may be interested in? Few respondents answered this question. Six programs used this question to highlight new initiatives in their region or partnerships with other programs. Seven programs used the question to note resource limitations either in their program or across their region. The two most pertinent of these were one response suggesting that outpatient rehabilitation resources had been dramatically reduced across the GTA, which had a perceived impact on their ability to provide these services. The other was a response from the North West LHIN where one 27

28 respondent noted that they often receive referrals from north of Sioux Lookout that they cannot accept. They noted that in this northern region, there were no outpatient rehabilitation resources available to stroke patients. Community-Based Rehabilitation Survey Response Rate Each LHIN has a single CCAC that coordinates services. The director of client services was contacted in each of the 14 LHINs and 13 responded to our survey. Structural Results Upon initial contact with a few CCACs, we inquired about the accessibility of stroke-specific information related to the number of patients served and visits provided. We were informed that information was not collected by diagnosis and that the resources did not exist to perform chart extractions. Therefore, ICES estimates of clients and visits from the upcoming technical report were used 7. The most recent information provided by ICES was from 2007/08. Patients discharged alive from an acute care facility who received home care services within 60 days were identified in the HCRS and the total and mean number of visits were calculated by LHIN. As an estimate of resource availability, the total number of clients and the total number of visits per rehabilitation discipline as a proportion of stroke patients discharged from an acute facility were calculated. Results of these calculations are presented in table 8. Table 8. Estimates of the number of stroke clients and the total PT,OT, and SLP visits provided by CCACs in 2007/08 by LHIN. LHIN Proportion of acute stroke discharges accessing CCAC PT visits/ acute stroke discharge OT visits/ acute stroke discharge SLP visits/ acute stroke discharge (1) Erie St. Clair (2) South West (3) Waterloo Wellington (4) Hamilton Niagara Haldimand Brant (5)Central West (6) Mississauga Halton (7) Toronto Central (8) Central

29 (9) Central East (10) South East (11) Champlain (12) North Simcoe Muskoka (13) North East (14) North West The proportion of stroke patients discharged alive from an acute care hospital that were able to access CCAC services in 2007/08 varied from a low of 30% to a high of 64%. Estimates of PT, OT, and SLP visits relative to the number of acute discharges offer a weighted measure of available resources. As may be expected, the availability of OT resources was greater than that of PT, which was greater than SLP. Still, there appears to be wide variation in the availability of resources across the province. In physiotherapy, the fewest available visits per discharge was 0.35 compared to a high of 1.59, while in OT, the low was 0.76 compared to a high of Speech language pathology was much less available across the province where no LHIN had greater than 1 visit per discharge available and the North West had only 0.14 visits available per discharge. Descriptive Results The surveys sent to directors of client services included 5 descriptive questions regarding how they provide services to stroke clients. The results for each question are summarized individually. I. In 2009/10, was there a wait list for access to CCAC services and, if so, how long was the average wait? Four of the 13 responding CCACs indicated that there was no wait list for access to CCAC services in 2009/10. These were the South-East, Central-West, Toronto-Central, and Mississauga-Halton LHINs. In the 9 remaining LHINs, all reported a system for prioritization such that high priority clients were admitted immediately and lower priority clients were placed on wait lists. In the three LHINs that provided actual values, the mean wait times for therapy services ranged from 48 to 219 days for OT, 56 to 145 for PT, and 28 to 323 days for SLT. II. In 2009/10, were clients admitted to CCAC care able to access in-home rehabilitation immediately and, if no, how long was the average wait? 29

30 Four CCACs indicated that once clients were admitted to CCAC services they had immediate access to rehabilitation services. Three of these LHINs (Central West, Toronto-Central, and Mississauga-Halton) had also reported no wait list for admission to CCAC. The Hamilton- Niagara-Haldimand-Brant LHIN, however, had noted wait lists for admission to CCAC services, but that once admitted, clients had immediate access to necessary rehabilitation. The opposite was true for the South-East LHIN where clients had immediate access to CCAC services, but were then prioritized for rehabilitation services and lower priority clients were wait listed. The other 9 CCACs each indicated that a priority system was again employed depending on the urgency with which the client needed rehabilitation. III. Were there any community-based rehabilitation programs specifically for stroke clients? Only two CCACs indicated that they had stroke-specific community rehabilitation programs in place in 2009/10. The South West LHIN had community stroke rehabilitation teams that coordinated care in three regions, while the South East LHIN reported additional funding for stroke rehabilitation provided through collaboration with the Stroke Network of South-eastern Ontario via Aging at Home. Two LHINs indicated that they did not provide stroke-specific community-based rehabilitation but did facilitate access to regional stroke programs that clients could access independently.. In the Chatham-Kent region of the Erie St. Clair LHIN, some stroke clients were able to access extended services in a Clubhouse program that provided exercise and recreation classes, while the Toronto Central CCAC noted prior participation in a research study of an inter-disciplinary team based approach that has not yet been fully implemented in the region. The remaining 9 CCACs indicated that they did not coordinate stroke-specific community-based rehabilitation programs. IV. Do you anticipate any changes in the above information in 2010 or 2011? Ten CCACs reported no anticipated changes in the coming years. Of the 4 LHINs expecting changes, the only indication of a negative impact on care was in the Mississauga Halton LHIN where they have had to implement of a wait list for non-urgent rehabilitation clients as a result of budgetary issues, but hope to reverse this in the new year. The Champlain LHIN reported 30

31 considering providing congregate rehabilitation in regions where no services currently exist, while the Central West LHIN has instituted enhanced service programs to facilitate early discharge home from hospital. Finally, the North Simcoe Muskoka LHIN has implemented a stroke pathway pilot project with contracted therapy providers to facilitate timely discharge to the community. The program will be evaluated and the end of the fiscal year. V. Is there any other important information about stroke rehabilitation coordinated by your CCAC that has not been covered by this survey? Six CCACs responded to this question. Five took the opportunity to note participation in local stroke or rehabilitation networking strategies. The Waterloo Wellington CCAC noted that a draft report had recommended establishing a specialized stroke service in the region and that the report was available online. Discussion Inpatient Rehabilitation As was expected, results from the inpatient rehabilitation survey suggest that LHINs across Ontario are employing a number of different strategies for providing inpatient rehabilitation to stroke patients. Very few regions provided short-stay rehabilitation, while all but one region had some form of slow-stream rehabilitation unit available. While most respondents acknowledged that providing stroke-specific rehabilitation was important, they also noted that this was not always easy to do. Depending on the region, this was handled in different ways. In the Central West LHIN, only two hospitals offered inpatient rehabilitation and respondents noted that most stroke patients were transferred to larger rehabilitation hospitals outside of their LHIN. In the North East LHIN where the population is more spread out, most stroke patients are transferred to 5 larger rehabilitation centers for the majority of their care and then smaller, more rural facilities help facilitate return to the community. The North West LHIN employed a similar strategy except that only a single inpatient rehabilitation hospital existed and all patients were transferred there for care. 31

32 Across the province, a focus on physiotherapy and occupational therapy was evident and the ratios of beds to FTEs did not vary dramatically between LHINs. However, speech language pathology was reported as being much more difficult to provide and the responsibility of SLPs therefore varied across a wider range. Similar ranges were noted for each of social work, recreational therapy and all assistants. Many facilities reported that limited rehabilitation budgets dictated their ability to provide services beyond PT and OT, so decisions needed to be made accordingly. Several interesting trends were also noted in the descriptive results. Only two facilities could provide documented values for the amount of therapy provided to stroke patients. All of the other facilities provided estimates. The most recent edition of the Canadian Best Practice Recommendations for Stroke Care suggest that patients in an inpatient rehabilitation unit should receive a minimum of 3 hours of direct task-specific therapy a day for at least five days a week. Very few facilities reported being able to meet this standard and most suggested that limited staff resources made this level difficult to achieve. Resource limitations were a common theme in survey responses. The vast majority of facilities noted that on top of not being able to meet daily recommendations for therapy, they also did not have resources to provide weekend therapy or replace therapists when they were sick or on holiday. Several respondents also made a point to note that limited outpatient and community rehabilitation services in their region were impacting their length of stay and forcing inpatient rehabilitation services to keep patients in hospital longer than they would have if outpatient rehabilitation were available. One positive note was that except for one facility, most centers that were undergoing or expecting changes reported they were increasing their capacity for stroke care. These increases included two facilities that were opening new rehabilitation units and two that were opening stroke-dedicated rehabilitation units. 32

33 Outpatient Rehabilitation The recurrent themes in responses to the outpatient survey were the lack of available information and the lack of resources. Only limited information was available regarding the number of total and stroke patients receiving outpatient rehabilitation in Ontario. As there is no centralized database or standardized recording system for outpatient information, very few facilities compiled information into an easy to access database. Making the situation even more challenging was that many centers indicated they did not have the time or resources to pull the information from their charts. As a result, it was impossible to get a baseline comparison for calculating resources consumption or therapist workload. The only information that was available to use for economic comparison was facility-level information that is in many ways inadequate. Some thought should be given to establishing an outpatient rehabilitation database in the future, as this is an important component of the rehabilitation continuum. The other issue that continued to appear was the lack of outpatient rehabilitation resources across the province. Although a number of facilities suggested that they would be increasing their outpatient rehabilitation resources, many of these respondents noted that these increases would not be sufficient to meet local demand. There were also a number of facilities that were closing their doors. In fact, two facilities had already closed and could not be contacted. Even worse, one respondent from the North West region indicated that north of Sioux Lookout, there are no outpatient rehabilitation programs available to patients. Respondents across the province continually mentioned that they were struggling to meet demand and often had to share resources with other programs. CCAC Rehabilitation The most recent obtainable information from ICES was for 2007/08 and, therefore, requires the assumption that service availability remained consistent through 2009/10. Also, the available data was collected via database linkage and may not include the services accessed by patients discharged from inpatient rehabilitation. Still, the data suggest that CCAC rehabilitation services 33

34 may be in short supply and vary across regions. It appears that most CCAC services are provided by occupational therapists, who often provide initial assessments of the home environment and follow-up care. Physiotherapy sessions were less frequently available and speech language pathology, although not required as often, was the most difficult to access service. The majority of responding CCACs indicated that they were forced to place non-urgent clients on wait lists. Depending on the rehabilitation service needed, clients often waited from one month up to a year. Respondents also consistently noted that clients were provided services based on their individual needs, not on their original diagnosis. Therefore, little stroke-specific information was available. In fact, only two CCACs noted offering programs specifically tailored to stroke patients. Inpatient Rehabilitation Key Findings Most facilities reported that limited rehabilitation resources hindered their ability to provide adequate rehabilitation to stroke patients Physiotherapy and Occupational therapy are the most uniformly available services while speech language pathology, social work, recreation therapy, and PT, OT and CDA assistants are more sporadically employed Very few facilities had documented the amount of therapy provided to patients making estimation of actual therapy provision challenging Resources for inpatient rehabilitation of stroke patients in Ontario appear to be on the rise Outpatient Rehabilitation No centralized database or routine data collection procedures exists for outpatient rehabilitation making data collection very challenging The majority of facilities were not able to provide information about the number of patients seen, the number of stroke patients seen, or the number of rehabilitation sessions provided More than 60% of outpatient rehabilitation programs reported undergoing changes now or in the near future. Since 2009/10, 8 outpatient programs have closed while only 2 new programs have opened. Survey respondents noted that outpatient rehabilitation resources were insufficient including a gap in the North West LHIN where no outpatient rehabilitation is available at all 34

35 CCAC Rehabilitation CCACs do not have stroke-specific information readily available The number of total rehabilitation visits per stroke patient varied dramatically between regions suggesting differences in service availability Most CCACs reported a wait list for non-urgent rehabilitation services that ranged from a month to nearly a year Only 2 of the responding CCACs reported offering some form of stroke-specific community-based rehabilitation [2] Assessing the Accessibility of Inpatient Stroke Rehabilitation in Ontario Introduction Assessing regional accessibility to rehabilitation in Ontario is challenging, in part, because of the limited availability of some important information. Large databases have been established to collect stroke-specific patient data from acute and inpatient rehabilitation facilities across the province. However, little information is available regarding community-based rehabilitation, and none is collected for outpatient rehabilitation services. As such, developing a detailed model of accessibility to rehabilitation that accounts for patient characteristics is impossible for anything beyond inpatient rehabilitation. In this phase of our study we focused attention on developing methodology for assessing accessibility to inpatient rehabilitation with the hope that similar methods could be applied to outpatient and community-based programs when more information comes available. One of the largest challenges to an assessment of healthcare accessibility is accounting for variation in patient characteristics. Evidence suggests that a variety of patient characteristics contribute to the suitability for and likelihood of being admitted to inpatient rehabilitation after stroke 8,9. Traditionally, patients with moderate disability have been considered the most ideal candidates for inpatient rehabilitation and are often selected preferentially. Patients with severe disability or more mild deficits may still be candidates for inpatient rehabilitation under certain circumstances, but may be more susceptible to exclusion based on resource limitations. 35

36 Traditionally, comparison of regional accessibility has often been made solely based on the proportion of patients admitted to rehabilitation in a given region. However, this fails to account for differences in the characteristics of the underlying population. This variation must be adjusted for before a realistic measure of rehabilitation accessibility can be generated. Furthermore, traditional measures of regional accessibility have focused only on patients admitted to inpatient rehabilitation, and have not explored the characteristics of patients not admitted. The purpose of this phase of our study was to develop a method by which the accessibility of inpatient rehabilitation could be compared between Ontario LHINs, adjusting for regional differences in patient characteristics. Methodology Cohort Development Patient data was drawn from the 2004/05 and 2008/09 editions of the Ontario Stroke Audit (OSA) by an analyst at ICES 10,11. The OSA is a bi-annual retrospective chart audit performed on a random sample of patients with stroke or transient ischemic attack (TIA) admitted hospital or seen in hospital emergency rooms in Ontario (an audit was not performed in 2006/07). The chart audit identifies demographic and medical characteristics of sampled patients as well as information about their acute medical management and discharge destination. Patients were excluded from the cohort if they did not have a primary diagnosis of stroke, experienced an inhospital stroke, died in the hospital, were discharged to another acute care facility, were diagnosed as TIA, or were never admitted to an acute hospital. Initial Canadian Neurological Scale (CNS) scores for patients with subarachnoid hemorrhages were not collected in 2004/05, so these patients were excluded from model development. Patients were also excluded if they met criteria for an inappropriate admission to inpatient rehabilitation. Criteria for inappropriate admissions were collected via a systematic review of articles assessing early supported discharge or home-based rehabilitation in lieu of inpatient rehabilitation. Studies were reviewed for information about the Functional Independence 36

37 Measure (FIM ) scores of patients who were included in home-based rehabilitation programs. The FIM is an assessment tool used to assess a patients need for assistance in performing activities of daily living. The tool is composed of 18 items, each of which is scored on a 7-point Likert scale where 1 denotes total dependence and 7 denotes total independence. A score of 6 on any item indicates independence with supervision. In our review, only a single study was located that reported item-level Functional Independence Measure (FIM ) scores for patients receiving home-based rehabilitation instead of inpatient rehabilitation 12. These mean values were therefore used as criteria for determining patients who may have been suitable for outpatient or community-based rehabilitation instead of inpatient rehabilitation (table 9). Rehabilitation patients who met or exceeded ALL of the mean values for each of the 15 reported FIM items were identified as patients who were inappropriately admitted to inpatient rehabilitation and were excluded from the cohort. This was done so that during model development, similar patients who likely do not require inpatient rehabilitation would not be identified as rehabilitation candidates. Table 9. Minimum item-level criteria for identifying possible unnecessary mild admissions to inpatient rehabilitation Grooming 6 Tub/ shower transfer 5 Bathing 4 Locomotion 5 Dressing upper 5 Locomotion (stairs) 4 Dressing lower 5 Comprehension 6 Toileting 5 Expression 6 Eating 6 Problem Solving 5 Bed Transfer 6 Memory 6 Toilet transfer 6 Using discharge records from the OSA, all included patients were divided into two groups retrospectively: those who were discharged to inpatient rehabilitation and those who were not. Results from our province-wide survey suggest that some facilities in Ontario provide inpatient rehabilitation to stroke patients but do not report to the NRS. This rehabilitation is generally offered in non-designated rehabilitation beds or in low-tolerance long-duration (LTLD) rehabilitation facilities. Accordingly, all patients whose OSA record noted discharge to inpatient rehabilitation were included as such regardless of our ability to locate a record in the NRS. However, classification of patients for whom the OSA discharge destination is not rehabilitation, but an NRS record was identified within 30 days of discharge is more challenging. It is possible that some of these patients were discharged from an acute facility to an intermediate destination when no rehabilitation bed was available, even though it was the intention of the discharging 37

38 physician to have them enter rehabilitation. It is also possible that after these patients were discharged from an acute facility, they experienced an additional medical setback that necessitated rehabilitation, but would not have been reflected by their acute patient characteristics. Due to this difficulty, any patients for whom the OSA discharge destination was not rehabilitation, but an NRS record was located <30 days post discharge were excluded from all analyses. Model Development The 2004/05 OSA was used as the model development cohort. A model was derived to predict the probability of admission to inpatient rehabilitation in Ontario based on patient characteristics obtained from the OSA chart review. The outcome of interest was therefore defined as discharge to inpatient rehabilitation (as denoted in the OSA) compared to no discharge to rehabilitation (as defined by OSA discharge and excluding patients for whom an NRS record was located). The candidate predictors explored are included in table 10. All variables (except for time from last seen normal) were analyzed in categorical form and information regarding categorization is also included in the table. Table 10. Candidate predictors of discharge to inpatient rehabilitation post-stroke explored during model development. Age Discharge modified Rankin History of arthritis (<50 vs vs. >79) Score (mrs) (0-2 vs. 3-5) Gender Post-stroke depression History of asthma (female vs. male) Previous living arrangement Second stroke in hospital History of atrial fibrillation (alone or with other) Marital status Post-stroke seizure History of coronary artery disease Arrived to ER from Patent worsening in hospital History of dementia (home or other) Stroke type (ischemic vs. hemorrhagic vs. undetermined) Hospital consult for palliative care History of depression Level of consciousness on ER arrival (alert vs. drowsy vs. unconscious) Most responsible physician (neurologist vs. other) Receipt of acute thrombolysis Admission Canadian Neurological Scale score (0-3 vs. 3-8 vs. >8) Time from last seen normal to ER assessment (hours) Hospital consultation for swallowing History of hemi or paraplegia Pre-event status (dependent vs. independent) History of diabetes Previous TIA Smoking history Previous stroke Family history of stroke 38

39 The model was developed using a logistic regression with backward elimination. Variables were removed sequentially at a significance level greater than 0.3. The final model was then tested for accuracy of prediction and goodness of fit. Model Application Once the final model had been established, it was applied to patient data from the 2008/09 OSA. Patient data was analyzed separately for each Ontario LHIN and the model was used to generate two statistics for comparison. First, the model was used to derive an estimate of the number of patients who should have been admitted to inpatient rehabilitation in 2008/09 based on the acute characteristics of patients in each LHIN. This estimate was then compared to the number of actual admissions to inpatient rehabilitation and a ratio of observed-to-expected admissions was generated. This statistic acts as a measure of accessibility to inpatient rehabilitation. A ratio greater than 1 suggests that the region is exceeding expectations of accessibility to rehabilitation adjusting for patient characteristics, while a ratio less than 1 suggests a region that is falling behind expectation. Second, the model was applied to each patient in the 2008/09 cohort to estimate their individual probability of admission to inpatient rehabilitation. A count of patients whose probability was greater than 0.5 and 0.7, but were not admitted to inpatient rehabilitation was then calculated for each LHIN. This statistic offers an estimate of the number of possibly good rehabilitation candidates who were unable to access services in each LHIN. 39

40 Figure 3. Schematic representation of methods for assessment of accessibility of inpatient rehabilitation in Ontario OSA 2004/05 OSA 2008/09 OSA 2004/05 LHIN 1 LHIN 2 Ratio (Observed rehab admissions/expected) Count (Patients with probability >0.5 or >0.7 not admitted) LHIN 14 Model Development Model Application Model Output Results Cohort Development After application of inclusion and exclusion criteria, a total of 3,602 patients were included in the cohort for final analysis. Details of complete exclusion results are summarized in table 11 and a flow chart of patient classification is presented in figure 4. Table 11. Description of patient identification from the 2004/05 and 2008/09 OSAs Ontario Stroke Audit (04/05 & 08/09) 9,217 EXCLUDED Non stroke diagnosis 341 In-hospital strokes 32 Died in hospital 858 Discharged to Acute care 484 Missing discharge date 1 Patient discharged to rehab but categorized as mild stroke* 14 40

41 Patients with TIA or mild strokes not admitted to acute hospital 3,761 Patients whose OSA discharge is not rehab, but an NRS 124 record was found INCLUDED 3,602 * Based on criteria derived from a systematic review of studies of early supported discharge to identify patients who likely did not require inpatient rehabilitation 13 Figure 4. Flow chart of patient identification and definition of outcome Model Development After exploration of 31 possible predictors of discharge to inpatient rehabilitation, 13 were eliminated and 18 remained (table 12). Four of the eighteen variables were stratified into three groups. Assessment of model accuracy noted that in the 2004/05 OSA, the final model was able to accurately predict discharge destination (rehabilitation or not) 82.5% of the time and the Hosmer and Lemeshow goodness-of-fit test resulted in a p value of 0.7 suggesting that the model fit the data well. 41

The Impact of Moving to Stroke Rehabilitation Best Practices in Ontario

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