WISCONSIN STROKE PLAN 2005 Rehabilitation of Stroke Patients

Transcription

1 WISCONSIN STROKE PLAN 2005 Rehabilitatin f Strke Patients A. Intrductin Rehabilitatin f Strke Patients: Ideal State 1. All strke patients with residual deficits receive an evaluatin fr rehab therapy during initial hspitalizatin. 2. Levels f rehabilitatin services and resurces are peridically evaluated. 3. Strke survivrs are referred t an inpatient, utpatient r hme-care service that prvides the survivr s medical and functinal needs. 4. Supprt systems are identified t ensure that patients discharged t hme frm hspitals and ther care facilities have apprpriate fllw up and primary care arranged n discharge. A systems apprach is particularly imprtant t prmte the effectiveness f rehabilitatin fr strke, especially given the imprtance f effective cmmunicatin amng prviders, facilities, patients and family members. Crdinatin and cllabratin amng all prviders thrughut the cntinuum f care are imprtant t ptimize patient utcmes, and rehabilitatin shuld begin as sn as medically feasible. The intensity f rehabilitatin services ften is a critical determinant in the recvery f strke patients. The use f crdinated, multidisciplinary strke rehabilitatin teams has been shwn t diminish mrtality rates fr patients with strke. In additin, strke patients wh receive care in an inpatient rehabilitatin facility are mre likely t return t the cmmunity and t recver activities f daily living. The linkages and crdinatin f care shuld be maintained t ensure adequate cmmunicatin amng the full set f prfessinals delivering rehabilitatin services. In additin, cmmunicatin shuld be pursued amng thse prviding utpatient care in varius settings, including secndary preventin. Wiscnsin Strke Plan - Rehabilitatin f Strke Patients 45

2 B. Current Status Please rate Wiscnsin s current status n Rehabilitatin f Strke Patients (n a scale frm 1 t 5, 1 being pr (des nt exist) and 5 being ideal state exists): Patients evaluated fr rehab Levels f rehab services are peridically evaluated Apprpriate referrals t rehab exist Supprt systems are ffered All strke patients with residual deficits receive an evaluatin fr rehab therapy during initial hspitalizatin Levels f rehabilitatin services and resurces are peridically evaluated Strke survivrs are referred t an inpatient, utpatient r hme-care service that prvides the survivr s medical and functinal needs Supprt systems are identified t ensure that patients discharged t hme frm hspitals and ther care facilities have apprpriate fllw up and primary care arranged n discharge Overall Scre Wiscnsin Strke Plan - Rehabilitatin f Strke Patients 46

3 C. Inventry Identify assets and resurces available t assist with the abve recmmendatins. Inventry f Rehabilitatin f Strke Patients Assets/Resurces AHA/ASA Organizatin (Surce) Tll-free Warmline and website Database f strke supprt grups Starting Nw (secndary preventin in the rehab setting) Strke Cnnectin Magazine Strke Grup Registry Peer Visitr Prgram Asset/Resurce (Identify/Describe) Assists with which Recmmendatin #4 Submitted by Dnna Pieschek, St. Vincent s Hspital, Rehab, Green Bay: CARF Prvides n-site review f Rehab prgram #2 JCAHO Prvides Strke prgram certificatin #2 St. Vincent s Hspital Functinal admissin screen dne n all patients t assess need fr PT, OT, Speech #1 St. Vincent s Hspital Case Manager Same case manager fllws all strke admissins and assists with mvement thrugh medical system and fllw-up #3 & 4 St. Vincent s Hspital Have lcal supprt grup; sign up patients fr Strke Cnnectin magazine; give educatin binder t patients #4 Submitted by: Angela Oldenburg, Blmer Medical Center, Blmer: Luther Hspital EC Inpatient Neursciences And Neur Intensive Care Blmer Medical Center Transitinal Care Unit Center fr Independent Living f WI Nursing and physician (Neurlgist r Neursurgen) cmplete neur exam and refer fr apprpriate therapies. Pt. is discussed daily during Cre Care Runds where therapies, nursing, scial services, pharmacy, respiratry therapy, chaplain, dietician, physiatrist are all present. Needs fr therapies and discharge planning are cmpleted during this daily meeting. Cre care runds 2x/week with entire team nted abve. MWF mini meetings fr team t cmmunicate plan f care and discharge planning. Cmmunity resurce available fr individuals wishing t return t wrk r assistance w/ hme adaptatin recmmendatins. Cmprehensive cmmunicatin is nt always present d/t cnfidentiality issues. #1, #3, #4 #3 #4 Submitted by: Dri Tke, St. Luke s Medical Center, Rehabilitatin, Milwaukee: St. Luke s Medical Center Measurement tls including FIMs, the mini mental exam, NIH strke scale, clinical pathways, Wiscnsin Strke Plan - Rehabilitatin f Strke Patients 47

4 Rehabilitatin interdisciplinary care plans, and general mbility/adl/cmp-cg-swallw evals fr therapy We use CARF and JCAHO quality criteria We have cunty and cmmunity van services fr transprtatin ptins We have a strke supprt grup and a strke at midlife supprt grup There is a rehab day prgram within ur system at a sister hspital a few miles away We have the full cntinuum f rehab care (ER-ICU-Acute-IRP-OP therapy and hme care) There are varius respite and cmmunity based services, meals n wheels, etc. There are multiple written pamphlets and bklets fr infrmatin, cmmunity health fairs, etc Being in a large urban area, we generally have the resurces, but we ften lack the family supprt t take advantage f all f the resurces. Submitted by: Janet Papenfuss, Franciscan Skemp Healthcare, Rehab Services, La Crsse standardized screening tl #1 Franciscan Skemp Healthcare P&Ps Franciscan Skemp Healthcare Emplyee(s) Franciscan Skemp Healthcare Unit Specific Meetings Franciscan Skemp Healthcare Staff Emplyees Unit Specific Meetings Staffing plans/bed availability cunts #2 Discharge Planners, Scial Wrkers, Rehab #3 Unit Patient Care Meetings and Staffings; SNF Patient Care Cnferences (staffings) #3 Case Managers; Discharge Planners/Scial Wrkers #4 Daily Neur Unit Meeting SHH Rehab Screening Frmat - SHH Submitted by: Kathy Msack, Sacred Heart Hspital, Eau Claire Interdisciplinary team at Sacred Heart Hspital meet daily t review cases and determine treatment and discharge needs. This meeting is attended by the Rehab Crdinatin, OT, PT, Speech, Nursing, Discharge planner, Dietician, Pharmacist and Scial Wrker. Need fr therapy and apprpriate level f Rehab is discussed at this meeting. The Rehab Crdinatr fllws and cmpletes infrmatin n a screening frm that when reviewing medical recrds and evaluating patients referred fr Inpatient rehabilitatin. This infrmatin is given t the Physiatrist prir t his visit with the patient and determinatin f the apprpriate setting fr the patient. #1 & 3 # 1 and 3 Wiscnsin Strke Plan - Rehabilitatin f Strke Patients 48

5 Rehabilitatin patient/team meetings Weekly interdisciplinary cnferences with therapies, nursing, sc service and physiatrist held fr each patient n the rehab unit t discuss patient prgress and discharge plans. The team meets daily withut the MD fr 15 t 20 minutes t crdinate patients n that team maximum f 8 patients. The patient, family, and team f staff meet the day after admissin t develp the patient s treatment plan tgether. Family cnferences with the team f staff, MD, patient and family as needed and always prir t discharge t make sure all needs have been addressed. Strke Supprt Grup A Supprt grup mnthly meetings facilitated by hspital staff held at SHH. #4 Discharge and fllw-up calls. SHH All patients discharged frm the Rehab unit receive a phne call ne r tw days fllwing discharge frm their primary Rehabilitatin RN t if they have any immediate unmet needs. Fllw phne calls 2 t 3 mnths fllwing discharge are made t gather FIM data and fllw up appintments are made with primary physicians at discharge fr fllw up f the patient. CARF Certifies Rehab Facilities hlding them t a high standard f care #2 JCAHO Surveys Institutins and awards Strke Certificatin as apprpriate t centers that meet their criteria. #2 #3 & 4 #4 Wiscnsin Strke Plan - Rehabilitatin f Strke Patients 49

6 D. Assessment fr Rehabilitatin f Strke Patients Recmmendatin 1: A strke system shuld ensure that all strke patients receive a standardized screening evaluatin during the initial hspitalizatin t identify the patients with residual impairment s the patients receive apprpriate rehab. Rated at 2.9 ut f 5; n standardized evaluatin tl exists that is cnsistently used fr screening and evaluatins; recmmend standardized tl. The standardized screening wuld have triggers t get the apprpriate disciplines r services invlved. Hspitals prvided sme type f screening and evaluatin but nt standardized Obstacles/Barriers: It wuld take sme wrk t cme up with a standardized tl Having it cver everything needed (because there are subjective things t lk at) Shrt enugh in length t nt be t lng, yet cver everything Critical success factrs: A taskfrce f rehab prfessinals t develp it thrughut the state Engage the rehab cmmunity in the prcess fr their buy-in and acceptance Teaching/training small hspitals withut rehab units t use the tl shuld be smething a nurse culd d; a standardized screening, ne that the nurse can d and triggers apprpriate services be invlved as ppsed t a cmprehensive dull therapy and nursing evaluatin This wuld prvide the baseline upn entering the acute system as t a basic functinal and mental baseline Evaluatins dne in the ED since patients can be seen and sent hme frm the ED withut necessary fllw up Assign respnsibility fr cnducting the assessment (filling it ut) shuld be held by nursing (regardless f hw the patient is admitted ie direct t a bed r thrugh the ED) Use f evaluatin screening tl at intake and transfer the screening prcess is nging -- fr example in the ED, n the flr, the transfers t flrs, the transfer t rehab nce the patient is in the rehab unit the screening prcess is dne Make physicians aware f the screening tl and everyne else invlved in the patient s care Usually it s OT that gets frgtten and they did get activities f daily living mentined, but nt Assessment f functinal status is pretty brad and we might miss a trigger if we re nt talking abut mbility/balance Include ability t take fd by muth r PO intake that wuld trigger a speech pathlgy cnsult. Cllabrate with the Acute Strke panel t crdinate n any inpatient assessment tl they may recmmend fr hspitals when the patient is first admitted such as NIH strke scale and hw that may tie int ur standardized screening tl. Idea fr Actin: Wrking up a standardized screening and evaluatin frm is smething that the cmmittee, that the panel rather wuld recmmend and maybe build an bjective arund. Recmmendatin 2: A strke system shuld peridically assess its level f available rehab services and resurces. Such an assessment shuld include the ttal number and types f beds available, the intensity f services prvided, the presence f trans-disciplinary crdinated teams, the adequacy f care crdinatin. The assessment shuld cnsider the current and future needs f the system fr inpatient care, etc. Rated at 1 ut f 5; number ne pretty much said it didn t exist in the state. Imprvement wuld be ding it at all; we said it was nt being dne. Obstacles/Barriers: The repsitry f data n # beds, types f beds, intensity f services prvided resides in different places per Mary J. Wiscnsin Strke Plan - Rehabilitatin f Strke Patients 50

7 In very rural areas f the state (far nrth) there are nursing hmes with certified Medicare beds and they d have therapies, but they are very limited there is n trans-disciplinary therapy team. Level f rehab available vs a metr area is very different. Need t knw mre than just certified beds; we need t knw capabilities. The thing I feel like is missing is the recmmendatin that we cllect all f the stuff but nt that we develp a guideline r a benchmark t say what s adequate. That s bth under the gal and strategy, but als under the recmmendatin. It just says, Cllect it, but what are ging t d with that, which I dn t have a gd answer t but it seems like the pint f cllecting it wuld be t determine if we have adequate resurces r where we need t get resurces, but we dn t really address what it is that we determine t be adequate. I think it shuld include utpatient and hmecare because the lack f sme f thse kinds f facilities change, in different cmmunities really affect hw yu treat patients. I think the part that s missing is we dn t have any infrmatin n hw many strke patients wuld need the varius levels. We can cunt hw many f the varius levels we have, but maybe putting these tw tgether, we culd cme up with that and it wuld be changing as the ppulatin changed. We re lking at what we have, but we re nt lking at what we need. We need t smehw lk at what we need. Data is nt currently available. Critical success factrs: Determine if there is a gap between what is available fr rehab services and resurces and # patients wh are nt receiving resurces. Panel des nt knw hw t begin t get the infrmatin; if anyne handles this data. Mary J cmments nt yet ; that is strke incidence and what a registry will prvide wh had a strke r TIA, wh had what kind f rehab and determine if the patient received what was needed. Develpment is lnger term, nt a shrt-term turnarund. Might be able t knw hw many peple served. Data cllected is fr patients currently there, nt ver 12-mnth perid. Define what data is cllected by the state and what needs t be cllected. Define gegraphically, by regin t knw what areas f the state have, and the barriers and bstacles in thse regins. It is cmmented that data may be kept by cunty culd the assessment be cnducted by cunty t have data and availability f service/resurce by cunty t knw the availability f services and resurces. Pst infrmatin frm data cllectin n the CVH Strke website t list what s available and have infrmatin psted in ne place accessible t all. It is cmmented that keeping infrmatin up t date is imprtant and have the psted infrmatin regularly reviewed (quarterly, semi etc) Currently Mike Yuan wuld be the webmaster fr the CVH Strke site wrking with Mary J Brink. Recmmendatin 3: Strke patients shuld be referred t an inpatient facility r an utpatient facility r a hme care service that prvides fr their medical functinal needs. The strke system shuld develp perfrmance measures that reflect the frequency at which patients receive the level f service that is apprpriate fr their cnditin. Research is needed t determine the impact f lcal practice variatin and reimbursement plicies n strke utcmes and patients will receive ther than the ptimal level f rehab service. Rated at 2.5 ut f 5. This is an imprtant measure because f reimbursement fr strkes Current Situatin: CARF accredited facilities have t cllect utcme data, but a majrity f facilities are nt CARF accredited. Thse that are have a standardized screening with triggers t get the apprpriate disciplines r services invlved and data is cllected fr gaps. D we knw which facilities are CARF accredited? (web site des nt list; need t submit request) JACHO accredited facilities cllect sme type f utcmes infrmatin (wh is getting what kinds f services) but we dn t knw hw t determine whether r nt there is a gap (refers back t #2). Can get discharge dispsitin based n acute DRG; dn t knw what is available frm ED (if it can be tracked) Individual rehab units track data; it wuld be desirable t knw what services patients gt when they left the hspital Critical success factrs: Discerning what CARF and JCAHO cllect fr data what data currently exists, is it publicly available? Agreement n apprpriate referral places fr strke survivrs Wiscnsin Strke Plan - Rehabilitatin f Strke Patients 51

8 Determine thrugh data cllectin if we are meeting what was defined as apprpriate services (n standard exists that places strkes int categries fr levels f services t administer) We are nt all n the same page in defining levels f strke and what kind f care they require Resurces r guidelines n this are available Key is research we really need data in sme cntrlled research t figure this ut; everybdy has an pinin I think the strke system needs t develp them (perfrmance measures) and the health facilities need t fllw them and recrd if they fllw them r smething. I dn t think that each facility, r grup f facilities can develp perfrmance measures. Then wuld they rll up t like a state reprt? I wuld think s and if we did that, we d get a lt f what we needed in number tw. Include in a survey if facilities are CARF (and at what level r fr what services) r JCAHO certified. Defining apprpriate referral fr strke survivrs wuld be a lng-term gal. Recmmendatin 4: Strke system shuld establish supprt system t ensure that patients discharged frm hspitals and ther facilities t their hmes have apprpriate fllw-up and primary care arranged n discharge. These effrts shuld include educatin and training fr the patient and the family members, clear cmprehensive timely cmmunicatin acrss the inpatient and utpatient pst-strke cntinuum f care is essential t ensure apprpriate medical and rehabilitatin care. Rated at 2.8 ut f 5. One f tw rated the highest (the ther at 2.9). Overall cmment: We felt we did this well fr the rehab units but nt necessarily always well frm an acute care unit especially in a small hspital. Obstacles/Barriers: Reimbursement Nt many health systems with acute care, rehab, hme care the full cntinuum Anther issue is distance patients get sent miles away (t their hmes) fr hme care Just plain availability f resurces depending n the part f the state yu are in gegraphic barriers Cmpliance. We recmmend but we dn t have really necessarily any cntrl ver fllw thrugh the cntinuum f care, especially nce they leave a facility t g t utpatient r hme care - that kind f thing, which culd certainly be addressed thrugh educatin, but it is an bstacle. Critical success factrs: It wuld need t be a requirement in rder t make it happen, like a basic JCAHO requirement. Idea: A case manager t cver the entire cntinuum f care Payers may have this available (Cmmunity Health Partnership, Eau Claire act as an insurer, need t be Medicaid eligible) New cncept in La Crsse: Patient care guide but nly develped fr cancer at this time Establish sme basic guidelines and get thse ut there n the Web Frm inpatient rehab unit: Care management initiatives (best practice) prvide what things t think f fr the patient and thrugh discharge (a checklist) Team cnferences all the disciplines and physicians present JCAHO recmmendatin: strke fllw up clinic Wiscnsin Strke Plan - Rehabilitatin f Strke Patients 52

9 E. Actin Plan Wiscnsin Strke Plan Rehabilitatin f Strke Patients Gal 1: A strke system shuld ensure that all strke patients receive a standardized screening evaluatin during the initial hspitalizatin t identify patients with residual impairments t ensure these patients receive apprpriate rehabilitatin. Strategy 1: Prmte and encurage use f a standardized screening evaluatin tl by nursing in the ED and/r during the initial hspitalizatin t prvide imprtant insights int the type and duratin f rehabilitatin therapy that is needed n a patient-bypatient basis. # Objectives Actin Steps 1.1A Crdinate with the Acute Strke Panel n assessments they are including (NIH scale etc) and cllabrate with them fr cntinuity. 1.1B Develp a standardized screening evaluatin tl fr use by Wiscnsin prviders in the ED and/r at initial hspitalizatin. 1.1C Encurage cnsistent use f a standardized screening evaluatin tl. Strategy 2: Cllabrate and integrate with Acute Strke Panel n assessments they are including in their plan. Recruit a task frce f rehab specialists t develp a survey and frm data develp a standardized screening and evaluatin tl fr the initial acute phase, determine what cmpnents are included and prvide recmmendatins fr implementatin and use. Investigate what ther states are using fr screening tls and prcess. Survey acute hspitals, ED departments n what they re ding nw fr screening (what prcess is used) and what standardized screening evaluatin tl is used (request sample). Develp a plan t engage the rehab cmmunity in the prcess fr their buy-in and acceptance. Crdinate and take int cnsideratin ther assessments recmmended and used such as JCAHO is stressing that the NIH Strke Scale be dne in the ED. That s what we re trying t d at ur site is make sure that every nurse in the ED knws hw t d the NIH scale. We have ther triggers as well in the cllabrative database that they fill ut when they assess any patient. There are triggers fr ther services, but that s anther tl that they wuld use wuld be the NIH scale if they had strke-like symptms. Develp and prmte a training prgram fr hspitals and in particular small hspitals n implementatin and cnsistent use f the standardized screening evaluatin tl. Recruit a task frce f rehab specialists t develp a training prgram. Develp a plan t prmte the standardized screening evaluatin tl and training (cnsider ffering webinars t hspitals). Ensure the standardized screening and evaluatin tl is readily available (psting n the CVH Strke website). Standardized screening evaluatins fr strke rehabilitatin shuld include a neurlgical assessment f residual deficits, assessment f functinal status (activities f daily living), cgnitive and psychlgical status, determinatin f prir functin status and medical c-mrbidities, the level f family/caregiver supprt, the likelihd f return t the cmmunity and the ability t participate in rehabilitatin services. Wiscnsin Strke Plan Primrdial & Primary Preventin 53 # Objectives Actin Steps See 1.1B abve. Include this infrmatin as part f the survey develped abve.

10 Gal 2: Strategy 1: A strke system shuld peridically assess its level f available rehabilitatin services and resurces. Ensure peridic assessment f available rehabilitatin services and resurces t include: ttal number and types f beds available, intensity f services prvided in different settings, presence f trans-disciplinary crdinated teams and adequacy f prgram f care crdinatin. This assessment shuld als cnsider: current and future needs within the system fr inpatient care, relative mix amng inpatient rehabilitatin facilities, skilled nursing facilities, nursing hmes, hme care services and utpatient services. # Objectives Actin Steps 2.1A Define what data is currently cllected, what Steps t determine where we are: needs t be cllected and survey t cllect data Wrk with the CVH Epidemilgist t reprt t the task frce the n data currently cllected by nt currently available. the state. Generate suggestins fr cllecting data nt currently cllected. Recruit a task frce t determine what data shuld be cllected by the state, define settings (inpt and utpatient rehab, rehab facilities, nursing facilities, hme health, extended care facilities, CBRF) and types and intensity f rehab services ffered. Develp and field a survey with web-based respnse (survey t include pinins n the adequacy f resurces ie questins abut where peple are sent fr strke rehab and is this the ptimal 2.1B Make infrmatin available n resurce cverage t meet strke rehab patient needs in regins f the state. place, r is it a site because there is n ther ptin, are resurces adequate). Steps t assess where we need t be and what we are ging t d abut it: Analyze data frm the survey abve and ther cllected data. Determine the state f strke rehab resurces in varius regins f the state and hw t imprve them where needed. Assess cnducting a peridic survey (every tw years??) t ensure knwing hw many strke patients there are, and assess if the state has adequate resurce cverage fr strke patients in regins f the state? Explre/Determine what is adequate cverage and what we wuld d abut it if we fund resurces were nt adequate. Publish infrmatin n the CVH Strke website Gal 3: Strke patients shuld be referred t an inpatient facility, an utpatient facility, r a hme care service that prvides fr their medical and functinal needs. Strategy 1: Develp perfrmance measures that reflect the frequency at which patients receive the level f service apprpriate t their cnditin. # Objectives Actin Steps 3.1A Investigate published guidelines and Recruit a task frce t investigate and make recmmendatins fr an acute strke algrithm and recmmendatins fr placement fr rehab care best practices fr placement fr rehab care after strke fr Wiscnsin strke care. Wiscnsin Strke Plan Primrdial & Primary Preventin 54

11 after strke (right level f care at right time fr best utcme) and best practices ccurring in ther states r within Wiscnsin. 3.1B Prmte acute strke algrithm fr placement fr rehab care after strke fr Wiscnsin strke patients. Determine a plan t prmte algrithm and best practice recmmendatins Strategy 2: Encurage research t determine the impact f lcal practice variatin and reimbursement plicies n strke utcmes in patients wh receive ther than the ptimal level f rehabilitatin services. # Objectives Actin Steps 3.2A Explre reimbursement issues in cmmn Survey hspitals and ther strke rehab sites regarding strke reimbursement issues. acrss the state. Determine what imprvements are needed and develp a plan t mve imprvements frward Gal 4: A strke system shuld establish supprt systems t ensure that patients discharged frm hspitals and ther facilities t their hmes have apprpriate fllw-up and primary care arranged upn discharge. Strategy 1: Prmte educatin and training t the patient and family members t ensure their awareness and knwledge f apprpriate fllw-up and primary care after discharge. # Objectives Actin Steps 4.1A Raise awareness amng patients and family Reinfrce strke signs and symptms and call 911 with strke patients, families, caregivers members and health care prviders n the Identify supprting strke resurces such as imprtance f fllw-up and primary care after Messages at discharge, educatinal materials fr patients and family, caregiver discharge. inf and supprt grups (and inf available in in different cmmunicatin mdes print, audi visual etc) Supprt systems resurces (case management, fllw-up clinic, patient fllwup practices, educatin and training available) Placing inf n the CVH Strke website dedicated t strke rehab fr patients and prviders etc Strategy 2: Prmte clear, cmprehensive and timely cmmunicatin acrss the inpatient and utpatient pst-strke cntinuum f care t assure apprpriate medical and rehabilitatin care. # Objectives Actin Steps 4.2A Encurage hspitals (and ther facilities) t Identify best practices and materials that will supprt this bjective fr strke patients, families adpt ED and acute care discharge systems that and caregivers. will autmatically cmmunicate with primary Prmte the need fr exit care infrmatin t be prvided t primary care physicians and ther care physicians and cpy patients n fllw-up fllw-up prviders. care (exit care sheet). Educate strke patients and family members and caregivers n the imprtance f fllw thrugh n recmmendatins fr apprpriate medical and rehab care. Wiscnsin Strke Plan Primrdial & Primary Preventin 55