Implementation of an Interprofessional Team Approach to Stroke Rehabilitation Among Stroke Survivors Using Home Care: Evaluation and Lessons Learned

Transcription

1 Implementation of an Interprofessional Team Approach to Stroke Rehabilitation Among Stroke Survivors Using Home Care: Evaluation and Lessons Learned Maureen Markle-Reid, RN, MScN, PhD Associate Professor and Acting Assistant Dean of Research, School of Nursing and Associate Member, Clinical Epidemiology and Biostatistics, McMaster University Stroke Collaborative 2011 October 17, 2011 Toronto, ON 1

2 Objectives 1. To provide a summary of our study on the feasibility, acceptability, effectiveness and costs of an interprofessional team approach to stroke rehabilitation among stroke survivors using home care 2. To discuss the issues and challenges involved in designing and implementing a practical, transferrable and sustainable interprofessional team approach to stroke rehabilitation in home care. 3. To provide recommendations for the design and evaluation of an interprofessional stroke rehabilitation team to enhance integration of the intervention into practice. 2

3 Co-Investigators: Camille Orridge, Robin Weir, Gina Browne, Amiram Gafni, Mary Lewis, Marian Walsh, Charissa Levy, Stacey Daub, Heather Brien, Lehana Thabane, Jacqueline Roberts Funded by ( ): Acknowledgements Canadian Institutes of Health Research Institute of Health Services and Policy Research Canadian Institutes of Health Research Knowledge Translation Branch Ontario Ministry of Health and Long-Term Care Toronto Central Community Care Access Centre McMaster University, System-Linked Research Unit on Health and Social Services Utilization 3

4 The Burden of Stroke in Canada Stroke is the leading cause of adult disability and the third leading cause of death in Canada More than 50,000 Canadians experience a stroke each year and more than 300,000 (1% of population) live with the ongoing effects 60% of stroke survivors are left with moderate-to-severe functional impairment, and 20% will have another stroke within 2 years Stroke costs Canadians 2.7 billion per year or $4 billion when indirect costs are included 4

5 The Burden of Stroke in Adult Stroke Survivors Using Home Care Services Aging of the population and corresponding increase in number of stroke survivors Only 20% of stroke survivors require institutionalization and most (up to 80%) will be living at home by 6 months poststroke 15-46% of stroke survivors are referred to home care services following acute hospitalization or inpatient rehabilitation In , 17,626 stroke survivors received services from home care programs in Ontario 5

6 What Can Be Done? A specialized interprofessional team approach to stroke rehabilitation can reduce stroke-related mortality and morbidity, length of stay, and costs in inpatient settings Interprofessional early supported discharge (ESD) interventions with continued rehabilitation in the early discharge phase (< 3 months) can improve health outcomes and reduce length of stay for selected mild-to-moderately disabled stroke survivors Over a 20-year period, organized stroke care, including specialized units and teams, could prevent 160,000 strokes and achieve $8 billion in net savings to the Canadian health care system 6

7 Definitions STROKE REHABILITATION is multidimensional, consisting of the combination and coordination of medical, social, educational, and vocational resources aimed at optimizing health and functional independence COMMUNITY REINTEGRATION, as part of stroke rehabilitation, includes facilitation of psychosocial coping and adaptation for the patient and caregivers, promotion of rejoining the community and re-establishing social and family roles, and enhancement of quality of life 7

8 Components of Community Reintegration Health management Life roles Social network Environment Communication Mobility Caregiver support (Heart and Stroke Foundation of Ontario, 2003)

9 Gaps in the Evidence on the Effectiveness of Community-Based Stroke Rehabilitation Limited information on the effectiveness of a specialized, interprofessional team approach to community-based stroke rehabilitation for stroke survivors using home care services Short-term ESD interventions Excluded stroke survivors with moderate to severe strokes with higher levels of disability, cognitive impairment or other co-morbid health conditions 9

10 Gaps in the Evidence on the Effectiveness of Community-Based Stroke Rehabilitation Lack of information on the effect of these interventions on depression, behavioural factors, health-related quality of life or caregiver outcomes Lack of information on the cost-effectiveness of communitybased stroke rehabilitation interventions from a societal perspective or the sub-groups of stroke survivors that benefit most Limited information on the characteristics of stroke survivors using home care services in Canada 10

11 Research Objective To determine the feasibility, acceptability, effects and costs of a12-month specialized interprofessional team approach to community-based stroke rehabilitation compared with usual home care among stroke survivors using home care services Markle-Reid, M., Orridge, C., Weir, R., Browne, G., Gafni, A., Lewis, M., Walsh, M., Levy, C., Daub, S., Brien, H., Thabane, L., & Roberts, J. (2011). Interprofessional stroke rehabilitation for stroke survivors using home care. Canadian Journal of Neurological Sciences, 38(1),

12 PARTNERSHIP PROJECT SYSTEM-LINKED RESEARCH UNIT, MCMASTER UNIVERSITY + COMMUNITY PARTNERS Toronto Central Community Care Access Centre Ontario Ministry of Health and Long-Term Care Bridgepoint Health Community Rehab Saint Elizabeth Health Care VHA Home HealthCare VON, Toronto Branch COTA Health 12

13 Participants and Setting Setting: Toronto Central CCAC Study Population (n=101): Confirmed diagnosis of stroke (first-ever or recurrent) or TIA within the previous 18 months Eligible for home care services through the CCAC Competent in English (or with an interpreter available) Living at home in the community (not in an in-patient facility or long-term care) Mentally competent to give informed consent (or with a substitute decision-maker available) Study Period: October 2005 to September

14 Study Flow Eligible CCAC Clients n = 299 Refused (n=135) Unable to contact (n=63) R Randomized (n = 101) Interprofessional Group (n = 52) Usual Home Care (n = 49) Drop 12 months (n = 9) Drop 12 months (n = 10) Analyzed (n = 43) Analyzed (n= 39) 14

15 RE-AIM Framework for Developing, Implementing and Evaluating Health Care Interventions Reach into the target population Efficacy or effectiveness Adoption by target settings or institutions Implementation consistency of delivery of intervention Maintenance of intervention effects in individuals and populations over time (Glasglow et al., 1999; RE-AIM, 2009) 15

16 Implementation Strategy: Ottawa Model of Research Use Assess Barriers and Supports Monitor Interventions & Degree of Use Evaluate Outcomes Evidence-Based Innovation: IP Stroke Rehabilitation Team Activities: Stakeholder analysis Environmental readiness assessment Analysis of Current Practice Implementation of Multifaceted IP Stroke Rehab Team Interactive educational workshops Outreach visits Reminders Audit & Feedback Adopt Intention to Use Outcomes Feasibility Acceptability Effectiveness Costs 16

17 Development of the Intervention Interprofessional team approach to stroke rehabilitation was derived from four sources: 1. Analysis of current home care practice 2. Literature on the key features of best practice models for community-based stroke rehabilitation 3. Existing practice guideline recommendations for stroke rehabilitation among adults 4. Principles of strengths-based practice 17

18 Analysis of Current Home Care Practice Delayed or limited access to professional services directed toward stroke rehabilitation and health promotion Limited provider expertise in stroke prevention, rehabilitation and community reintegration Limited follow-up care Lack of interprofessional collaboration No evidence-based practice standard for stroke prevention, rehabilitation and community reintegration in home care Lack of standardized assessment tools across disciplines Continuity of care provider not assured 18

19 Key Features of Best Practice Models for Community-Based Stroke Rehabilitation Coordinated interprofessional team approach Providers with stroke expertise Early access to appropriate services Regular follow-up care using standardized screening tools and evidence-based practice guidelines Intensive case management Multi-component strategies aimed at stroke prevention and rehabilitation that are tailored to individual needs Formal mechanisms for communication among healthcare providers Referral to and coordination of community services 19

20 Best Practice Guideline Recommendations Community Stroke Best Practice Guidelines RNAO Best Practice Guideline: Stroke Assessment Across the Continuum of Care Heart and Stroke Foundation of Ontario Best Practice Guidelines Tips and Tools for Everyday Living: A Guide for Stroke Caregivers

21 Strengths-Based Practice Strengths-based practice is a directive client-centred counseling style that emphasizes individual s selfdetermination, strengths and abilities, not their deficits, weaknesses or problems. Overall goal facilitate community reintegration by empowering and supporting individuals to develop goals and plans to achieve them, and enhance selfcare and independence.

22 Analysis of Current Home Care Practice Barrier Proposed Strategy to Overcome Barrier Delayed or limited access to professional home care services Lack of staff education Limited follow-up care Lack of IP collaboration No evidence-based practice standard for stroke prevention, rehabilitation and community reintegration Lack of standardized assessment tools across disciplines Lack of continuity of home care provider Structured and planned home visits and access to care coordination over 12-months Interactive educational workshops for IP team Structured and planned home visits and case conferences over a 12-month period Monthly IP case conferences over 12-months Development of an evidence-based stroke rehabilitation management protocol and a stroke risk assessment tool Utilization of common standardized assessment tools to assess stroke risk and factors that influence community reintegration Continuity of home care service provider through the use of a dedicated team 22

23 Specialized IP Team Referral and Linkage to Health Services CCAC Care Coordination Monthly Case Conferencing Client & Caregiver Stroke Education Strengths-based practice Structured and Planned Home Visits Evidence-Based Strategies for Stroke Prevention, Rehabilitation & Community Reintegration Stroke Risk Assessment and Screening

24 Steps Involved in Designing the Intervention Formed an implementation team of providers, managers and researchers to: Develop a stroke rehabilitation management protocol and a stroke risk assessment tool using existing best practice guidelines Modify strengths-based practice to make it usable by stroke survivors and their caregivers Identify dedicated teams of IP home care providers from the partner agencies 24

25 Interprofessional Stroke Team West District North District Toronto Central CCAC Care Coordinators (TCCCAC) Registered Nurses (SEHC) Physiotherapists (BH, CH) Occupational Therapists (BH, CH) Speech Language Pathologists (BH, CH) Social Worker (BH, CH) Registered Dietitians (VON) Personal Support Workers and Supervisors (VHA) Central District East York District East District

26 Steps Involved in Designing the Intervention Formed an implementation team of providers, managers and researchers to: Develop a detailed intervention protocol Establish the referral process and guidelines for communication among providers and across agencies Develop home care provider and client materials to support the delivery of the intervention Develop role-appropriate training manuals for the home care providers 26

27 Resources Developed Training manuals for health care professionals Stroke risk assessment tool Stroke rehabilitation management protocol Standardized clinical assessment tools Case management record Team meeting record/progress report Client service plan Letter to physicians In-home team communication log 27

28 Standardized Screening Tools Implemented by Teams Dimension Global Functional Ability Community Reintegration Health-Related Quality of Life and Functioning Cognition Gait and Balance Standardized Screening Tool RAI-HC Reintegration to Normal Living Index Stroke Impact Scale-16 Short Portable Mental Status Questionnaire Performance-Oriented Mobility Assessment Environmental Risks Depression and Anxiety Skin Integrity Nutritional Risk HOME FAST Screening Tool Kessler-10 Braden Scale SCREEN II Caregiver Burden/Strain Caregiver Strain Index 28

29 Implementation Strategy: Ottawa Model of Research Use Assess Barriers and Supports Monitor Interventions & Degree of Use Evaluate Outcomes Evidence-Based Innovation: IP Stroke Rehabilitation Team Activities: Stakeholder analysis Environmental readiness assessment Analysis of Current Practice Implementation of Multifaceted IP Stroke Rehab Team Interactive educational workshops Outreach visits Reminders Audit & Feedback Adopt Intention to Use Outcomes Feasibility Acceptability Effectiveness Costs 29

30 Implementation of the IP Stroke Rehabilitation Team Intervention Interactive educational workshops with home care providers Additional educational workshops by the partner agencies Imbedded reminders for home visits and team meetings Scheduled outreach visits with the CCAC Care Coordinators and the IP teams Reminders Audit and feedback 30

31 Implementation Strategy: Ottawa Model of Research Use Assess Barriers and Supports Monitor Interventions & Degree of Use Evaluate Outcomes Evidence-Based Innovation: IP Stroke Rehabilitation Team Activities: Stakeholder analysis Environmental readiness assessment Analysis of Current Practice Implementation of Multifaceted IP Stroke Rehab Team Interactive educational workshops Outreach visits Reminders Audit & Feedback Adopt Intention to Use Outcomes Feasibility Acceptability Effectiveness Costs 31

32 Data Collection Quantitative Methods: Multiple sources of data: In-home interviews CCAC data Service provider agencies Measurement of clinical outcomes: Baseline and12 months Qualitative Methods: Focus groups with study intervention personnel 32

33 Effects: Primary Secondary Costs Feasibility Research Outcomes Variable Health-related quality of life & function Measure SF-36 Health Survey Number of strokes during 12 months Sociodemographic Q Anxiety and depressive symptoms CES-D & Kessler 10 Perceived social support Community Reintegration Health Services Utilization, from a societal perspective Number of home visits and team meetings Perceptions of intervention by intervention providers Fidelity to treatment PRQ-85 RNLI Index HSSUQ and CCAC data CCAC records Focus group interviews Fidelity scale Acceptability Engagement rate CCAC records Perceptions of intervention by intervention providers Focus group interviews 33

34 Statistical Analysis CONSORT guidelines Descriptive Test for difference due to intervention: Repeated measures of analysis of variance to compare the mean changes in scores for primary and secondary outcomes from baseline to 12-months; Kruskal-Wallis test. Subgroup analysis using regression to identify what clients with what characteristics benefited most from the intervention using the SF-36 physical functioning subscale score at 12 months as the dependent variable.

35 RESULTS: Baseline Demographic Characteristics (n=82) 55% were males Average age was 73 years 76% had their first-ever stroke 70% were within their first 6 months post-stroke 60% had 2 or more co-morbid health conditions 35% had 4 or more co-morbid health conditions 31% screened positive for depression 11% were cognitively impaired 70% were limited in basic ADLs 74% to 92% were limited in IADLs 55% were living with others 35

36 Number of Home Visits by Health Professionals Over 12-Month Follow-Up (n=82) IP Team Usual Home Care 5 0 CCAC CC RN OT PT RD SW SLP 36

37 Use of Personal Support Services Over 12- Month Follow-Up (n=82) IP Team Usual Home Care 50 0 Number of Hours 37

38 Results: Effects Change in Mean SF-36 Physical Functioning Score over 12-Month Follow-Up (n=82) Interprofessional Group Usual Home Care T1 T2 T2-T1 Mean difference 5.87 (95% CI -3.98, 15.73); p =

39 Results: Effects Change in Mean SF-36 Social Functioning Score over 12-Month Follow-Up (n=82) Mean difference 9.03 (95% CI -7.50, 25.57); p =

40 Results: Costs Total Mean 12-Month Per Person Costs of Use of Health Services, from a Societal Perspective (n=82) $20,000 $20,795 $18,044 $10,000 $0 Interprofessional Group p=0.76 Usual Home Care 40

41 Qualitative Results: Acceptability and Feasibility Promoted adoption of evidence-based standards for stroke care; Fostered the development of networks and alliances among individuals, service providers and organizations involved in providing community-based stroke care; Expanded knowledge and skills in areas of stroke care, health promotion, chronic disease management and interprofessional collaboration; Enhanced knowledge about the risk factors for stroke and the importance of stroke prevention; Optimized professional roles and responsibilities

42 Perceptions of the Intervention by IP Team The interprofessional approach enhanced my knowledge and awareness of the needs of stroke survivors Increased my teamwork skills; provided me with an opportunity to work intensely with stroke survivors in the community and address their needs By meeting as a group, we were able to gain a more in depth understanding of the client s needs The team approach promoted consistency in the information that the client and caregiver received from the different team members A more cohesive plan of care as a result of the enhanced communication between interdisciplinary team members

43 CONCLUSION A 12-month specialized, interprofessional team approach to community-based stroke rehabilitation is more effective and no more expensive than usual home care in improving health-related quality of life (physical functioning and social functioning) among stroke survivors using home care services There was no particular subgroup of stroke survivors that benefited more from the interprofessional team approach Acceptable and feasible approach in the home care setting. 43

44 Implications Home care has the potential to play a pivotal role in providing community-based stroke rehabilitation to adult stroke survivors Most effective community-based stroke rehabilitation programs include: Specialized and coordinated interprofessional team approach Regular follow-up care using standardized screening tools and evidence-based practice guidelines Intensive case management Multi-component interventions tailored to individual needs Early access to appropriate services Formal mechanisms for communication among healthcare providers Referral to and coordination of community services 44

45 Implications The greatest opportunity for recovery after a stroke is a system of well-organized rehabilitation Bringing about change will require effort at multiple levels: Stroke survivors and their families (awareness of risk, readiness to change) Health care providers (implementation of evidence-based protocols) Team (implementation of collaborative practice) Organization (integration of services) Implementing a specialized interprofessional team approach is as much about changing the system as it is about changing individual providers practice 45

46 RE-AIM Framework for Developing, Implementing and Evaluating Health Care Interventions Reach into the target population Efficacy or effectiveness Adoption by target settings or institutions Implementation consistency of delivery of intervention Maintenance of intervention effects in individuals and populations over time (Glasglow et al., 1999; RE-AIM, 2009) 46

47 Implementing an IP Stroke Rehabilitation Team Intervention What are the issues? Balancing intervention fidelity and intervention adaptability Enhancing the acceptability of the intervention Sustaining the intervention over time 47

48 Balancing Intervention Fidelity and Intervention Adaptability What are the issues? Non-adherence to research protocol Reorganizations and leadership changes within the home care program Intervention was complex and required changes in attitudes and behaviours Building effective teamwork Inter-organizational collaboration 48

49 Balancing Intervention Fidelity and Intervention Adaptability What can be done? Environmental scan and stakeholder analysis to identify the barriers and facilitators to implementation Standardized educational sessions Clear intervention protocols and imbedded reminders Monitor fidelity to treatment Identify core/adaptable components of the intervention Document processes and outcomes of intervention adaptation 49

50 Enhancing the Acceptability of the Intervention What are the issues? No single intervention or mix of services will meet the needs of all seniors Interventions need to respond to an individual s readiness to change Complex intervention required changes in attitudes and behaviours among clients and providers 50

51 Enhancing the Acceptability of the Intervention What can be done? Developing relationships and building trust and respect among the partners; Determine client, unpaid caregiver, and formal care provider s attitudes toward the nurse-led intervention Support/facilitate changes in clinical practice Tailor the intervention to individual client needs and preferences Monitor participant adherence to intervention protocol and effect on outcomes 51

52 Sustaining the Intervention over Time What are the issues? Economic and organizational obstacles Organizational culture (innovativeness) Inter-organizational collaboration Competing demands (workload) Natural resistance to change 52

53 Sustaining the Intervention over Time What can be done? Utilize existing home care services and supports Clearly delineate roles and responsibilities Create provider-specific incentives for change Engagement and support by senior and clinical leaders Facilitate ongoing changes in practice and behaviours: outreach visits, audit and feedback, reminders 53

54 Lessons Learned Intervention studies among frail home care clients are complex to design and implement in the real world setting Engaging partners in all aspects of the research is critical Design and evaluation of health care intervention studies should reflect the complexity and context of clinical practice Evaluation of health care interventions requires use of quantitative and qualitative evidence Greater attention to possible challenges to meeting the goals of the RE-AIM framework is needed during intervention development and evaluation to increase the ability to get efficacious interventions put into practice. 54

55 New Solutions are there: We just don t always see them

56 THANK YOU! Dr. Maureen Markle-Reid, R.N., MScN, Ph.D. Principal Investigator McMaster University, Faculty of Health Sciences, 1200 Main Street West, HSC 3N28H, Hamilton, Ontario L8N 3Z5 Tel: , ext Fax: