1 AlphaFIM Instrument Tool 1 Mild Stroke Project (Part II) Report Prepared by: Carmel Forrestal Regional Stroke Rehab Coordinator 1 The FIM instrument and AlphaFIM instrument referenced herein are the property of Uniform Dataa System for Medical Rehabilitation (UDSMR), a division of UB Foundation Activities, Inc. (UBFA) All rights reserved. All marks associated with AlphaFIM, FIM and UDSMR are owned by UBFA. 1 Page1
2 Index: Background--------------------------------------------------------------Pg.3 Project purpose---------------------------------------------------------pg.3 Results--------------------------------------------------------------------Pg.5 Part I: Overall Data---------------------------------------------Pg.5 Part II: Comparison of patients going to IP rehab v Home or Home with Services-------------------------------Pg.7 Part III: Rehab Patient Groups------------------------------Pg.9 Community and Ambulatory Care Services West GTA Region In 2010/11----------------------------------------------------------------Pg.13 Summary-----------------------------------------------------------------Pg.14 Discussion---------------------------------------------------------------Pg.14 2 Page2
3 Background: In 2009, the West GTA Stroke Network reviewed data on 215 stroke patients to determine the discharge disposition of acute stroke patient population within the region and specifically with mild stroke patients with projected FIM rating over 80. It was found that 58% of all cases had a FIM rating 80 and 30% of this cohort went to inpatient rehabilitation. Further investigation was deemed appropriate and so a prospective study of mild stroke patient in the West GTA Region was proposed to identify potential rationale for referral to inpatient rehabilitation. Project Purpose: The purpose of the project was to perform a prospective study of 100 stroke patients in an acute care setting in the West GTA Region with an early FIM score >80 who are discharged to in-patient rehabilitation (IP Rehab) or home with services (HwS). 2 Document the following demographics/functional status and indicators to identify potential rationale for referral: Age Projected Raw Cognition FIM rating Projected Raw Motor FIM rating Projected Full FIM rating Hours of Help Needed Time to administration of the AlphaFIM rating Discharge disposition from acute care LOS acute care LOS rehab Co-morbidities Cognition Communication Social Support Environmental access barriers In addition, the following information was obtained for the collection period: Availability of core services (i.e.pt, OT, SLP) in the ambulatory care and CCAC. Average wait list for core services in ambulatory care and CCAC 2 The period for data collection was extended to gather information for up to 200 patients. The original parameters of collections was for patients with projected rating of >80 100, however, data submitted included patients with early projected FIM rating >100 and was included due to the small sample size available. 3 Page3
4 Project Goal: The main goal of the project was to provide qualitative information in addition to the quantitative projected FIM data regarding mild stroke patients being admitted to an inpatient rehab bed, with the potential to: Identify barriers/gaps in referral to ambulatory/community settings Assist with identification of processes to improve triage and transition of mild stokes to the most appropriate rehab setting Free up inpatient rehab beds for moderate to severe strokes (increase capacity in system) Methodology: The data was collected by designated coordinators from four organizations, for the period of April 2010 to September 2011, and entered into an Excel spreadsheet. The data collected did not include personal or hospital identifiers and was collated by the Network office. AlphaFIM Rating: The AlphaFIM Instrument is an abbreviated version of the FIM instrument which was designed to assess disability and functional status in the acute care setting. There are eighteen items in the FIM instrument but only six items are used in the AlphaFIM ; four motor items and two cognitive items. The total score of the four motor items and two cognitive items are entered into an online portal which, via an algorithm, projects the Raw Motor Rating and Raw Cognition Rating, as well as the Hours of Help Needed. The Projected Full FIM rating is obtained by adding the total of the raw cognition rating and raw motor rating. 4 motor items Raw Motor Rating + = Projected Full FIM Rating (PFF) 2 cognition items Raw Cognition Rating Hours of Help Needed = the number of hours per day that would be required of a helper to help the patient perform basic activities of daily living Highest Raw Motor Rating = 81 Highest Raw Cognition Rating = 35 Highest Projected Full FIM Rating = 116 4 Page4
5 Results: Part I: Overall Data Data was collected on 177 patients. Most of the data came from Trillium Health Centre (n=132 or 75%) Median age: 71 (range 27 95) Median time to administration of the AlphaFIM : 5 days (range 1 14) Median LOS in acute care: 7days (range 2 33) Median LOS In patient Rehab: 13 days (range 6 37) * *LOS Rehab data was available for 58/89 patients Projected FIM Rating: Projected Raw Motor (max. rating=81) Projected Raw Cognition (max. rating=35) Median 64 28 93 Range 47-81 7-35 81-116 Projected FIM Rating (max. rating =116) The majority of patients (60%) needed 1-2 hours of help. Cognition deficits Communication deficits Cog. & Comm. deficits 40% 41% 23% Lives alone Social Support Environmental Access Barriers 14% 82% 29% Discharge Disposition: Home Home w IP Rehab LTC Other* Repatriated Slow Unknown Services Stream/Reactivation n 35 23 89 1 22 4 1 2 % 20 13 50 0.5 12 2 0.5 1.0 (*palliative, other acute, deceased) Page5 5
6 Comorbidities: 90/177 (51%) had one or more comorbidities: COPD CHF Previous Stroke/TIA Dementia (incl. Alzheimer s) Coronary disease Other physical deficits* (e.g. amputation etc.) # 7 5 26 10 45 40 % 4 3 15 6 25 23 (*MS, Hips/Knees, Parkinson s, Amputation etc ) The median age of patients was 71 years. The median time to administration of the AlphaFIM Instrument Tool was 5 days. (Note: at the time of collection the recommended time to administration was 3-5 days.) The median projected FIM rating was 93 The median LOS in acute care was 7days. (range of 2-33 days) 40% of patients had cognitive or communication deficits 29% lived in homes with environmental access barriers The majority of patients had social support and lived with someone 51% had one or more co-morbidities 50% (n=89) of the patients went to inpatient rehab. The median LOS for IP Rehab was 13 days* (Based on LOS data available for 58/89 patients.) * The recommended minimum LOS for in-patient rehab is 14 days. (Ref: Stroke Distinction Program Accreditation Canada) Page6 6
7 Part II: Comparison of patients going to Inpatient rehab (IP Rehab) and patients going home or home with services (H & HwS) There were 57 patients who went Home with or without Services and 89 patients who went to Inpatient Rehab IP Rehab median(range) Age 70 (27-95) LOS Acute care (days) 7 (2-17) H &HwS median (range) 76 (31-93) 7 (2-33) Time to Administration of AlphaFIM (days) 5 (1-14) 5 (1-8) Median Raw Rating and projected FIM rating (PFF) according to discharge Destination: Discharge Destination Home Home w Services Rehab Median (Range)Raw Motor 67.5 (52 81) 68 (53 78) 60(47 81) Median (Range) Raw Cognition 29 (14 35) 28 (16 35) 28 (7 35) Median (Range)PFF 96.5 (81 116) 95 (81 100) 89 (81 106) IP Rehab (n=89) Living Alone 17% Social Support 79% H & HwS (n=58) 11% 81% Environmental Access Barriers 39% 11% Page7 7
8 Co-morbidities per IP Rehab and Home with or without services Co-morbidity Rehab n=89 H&HwS n=58 COPD 4% 4% CHF 2% 2% Previous stroke/tia 18% 16% Dementia (incl. Alzheimer s) 6% 5% Coronary Disease 22% 26% Other physical deficits* 30% 18% (*MS, Hips/Knees, Parkinson s, Amputation etc ) Patients going home with or without services had a higher median age. A considerable number of patients (39%) going to in-patient rehab lived in homes with environmental access barriers The co-morbidity of other physical deficits was prevalent in patients discharged to rehab Patients going to inpatient rehab had lower median motor rating. There was no significant difference in cognition rating between the two groups. Page8 8
9 PART III: The Rehab Patient Group (RPG) In 2004, the Joint Policy and Planning Committee proposed a prospective payment system for patients admitted to in-patient rehabilitatio n in Ontario, the Rehab Patient Group (RPG). Schematic of the RPG group classification for stroke: Under this classification system, severity of stroke is classified as follows: Mild 1160, 1150 Moderate 1140, 1130, 1120 Severe 1110, 1100 Page9 9
10 Median projected FIM rating according to RPG classification: RPG 1120 and 1150 had lower raw motor rating. RPG 1130 had a lower cognition rating 1120 1130 1140 1150 1160* n=9 n=75 n=19 n=72 n=2 Raw Motor Median (range) 49 (47-50) 74 (58-51) 68 (56-74) 60 (51-68) 76 Raw Cognition Median (range) 35 (32-35) 21 (7-35) 27 (26-28) 33 (30-35) 35 Projected Full FIM 82 95 96 93 111 Median (range) (82-84) (81-100) (81-100) (83-100) Number of patients discharged to IP rehab or home with or without services by RPG classification: A larger number of patients fell into the RPG 1130 and 1150 classification and went to in patient rehab. All of the RPG 1120 and 63% of the RPG 1140 went to rehab. 3 IP Rehab n (%) H & HwS n (%) 1120 n=9 1130 n=75 1140 n=19 1150 n=72 1160 n=2 9 (100) 33 (44) 12 (63) 34 (47) 1 (50) 0 23 (31) 7 (37) 27 (38) 1 (50) 3 Patients in the 1140 rehab cohort had a median age of 62(the lowest of all the RPG rehab cohorts and 7/12 (58%) had homes with environmental access barriers. Page10 10
11 Comparison of Median Raw Rating and Projected FIM Rating of RPG s according to discharge destination: Patients going to inpatient rehab had a lower raw motor rating, particularly in the RPG s 1120 and 1150. A lower raw cognition rating was seen in the RPG 1130 cohorts that went both to inpatient rehab and home with or without service. Discharged Home or Home with Services: 1120 1130 1140 1150 1160 n=1 Raw Motor Rating median (range) none 74 70 64 81 (52-81) (61-74) (52-68) Raw Cognition Rating median(range) none 21 28 33 35 (14-35) (26-28) (30-35) Projected FIM Rating median (range) none 95 96 95 116 (81-99) (81-98) (83-100) Discharged to IP Rehab: 1120 1130 1140 1150 1160 n=1 Raw Motor Rating median (range) 49 67 63 58 71 (47-50) (58-81) (56-73) (51-67) Raw Cognition Rating median(range) 35 (32-35) 21 (7-25) 27 (26-28) 33 (30-35) 35 Projected FIM Rating median (range) 82 (82-84) 89 (81-100) 87 (84-100) 90 (84-97) 106 Page11 11
12 A comparison of Cognition/Communication deficits of RPG 1130 going to in patient rehab or home with or without services: A large percentage of the RPG 1130 cohort going to inpatient rehab had cognition or communication deficits as reported by clinicians. Of the RPG 1130 cohort going to inpatient rehab, a smaller percentage had cognition and communication deficits as opposed to cognition or communications deficits alone. Conversely, of the RPG 1130 cohort going home with or without services, a larger percentage had cognition and communication deficits as opposed to cognition or communication deficits alone. RPG 1130 Rehab n=33 RPG 1130 Home & Home w Services n=23 Cognition deficits n (%) Communication deficits n (%) Cog. & Comm. Deficits n (%) 20 (61%) 30 (91%) 17 (52%) 3 (13%) 5 (22%) 10 (43%) A comparison of projected FIM Rating of the 1130 RPG patients who went to rehab or home with and without services and cognitive and communication deficits: The median raw motor rating of patients in RPG 1130, discharged to rehab, with cognition and communication deficits was slightly lower than those discharged home. However the median raw cognition rating was slightly higher. RPG 1130 cohorts with Cognition & Communication deficits Raw Motor Rating median(range) Raw Cognition Rating median(range) Projected FIM Rating median(range) RPG 1130 Rehab 74 19 92 n=17 (60-81) (12-25) (81-97) RPG 1130 Home & Home w Services 78 16 95 n=10 (74-81) (14-23) (94-97) Page12 12
13 A large number of patients discharged to inpatient rehab were classified as RPG 1130 and 1150. However: 100% of RPG 1120 and 63% of RPG 1140 were discharged to inpatient rehab. Patients in the RPG 1120 and 1150 going to inpatient rehab had a lower motor rating A majority of the patients in the RPG 1130 had cognitive and/or communication deficits as reported by clinicians and noted by the lower raw cognition rating. A larger percentage of the RPG 1130 rehab cohort had cognition or communication deficits alone than compared to those that had cognition and communication deficits. In this sample, the presence of cognitive and communication deficits as reported by clinicians and reflected in the projected FIM rating did not appear to influence discharge to inpatient rehab. Level of Services in the Community and Ambulatory Care Setting West GTA Region 2010/11: An environmental scan of rehabilitation services, including ambulatory care, was completed by the West GTA Stroke Network at the time of the data collection period. The average wait time for outpatient services varied between 4-8 weeks, although one organization reported a wait time of one week for patients discharged from the hospital setting. In the ambulatory care setting, two organizations reported having approximately 0.5 full time equivalents (FTE) for the core services of OT, PT and SLP; one organization had 1.0 FTE for OT and PT and 0.1 FTE for SLP and one organization had 2.0 FTE for OT and PT and 1.0 FTE for SLP. No data was available for CCAC visits at during the time this project took place. However, in 2008/09 and 2009/10, data for Central West CCAC and Mississauga Halton CCAC, indicated that the mean number of visits per client was approximately three for OT and SLP and four for PT. 4 4 Exhibit 4.1 Ontario Stroke Evaluation Report 2012 Page13 13
14 Summary: Data was collected for a total of 177 patients. The median length of stay (LOS) in acute care for this sample was within the recommended time of seven days. 5 However, the range indicated some outliers. 50% of the mild stroke patients included in this pilot project went to inpatient rehab. LOS in rehab was not available for all the patients discharged to that setting but 31/89 (35 %) had a LOS below the recommended 14 days as set by Stroke Distinction Program, Accreditation Canada. The primary characteristics of patients discharged to in patient rehab, as defined by this small sample group, appeared to be: A lower projected raw motor rating The co-morbidity of other physical deficits The presence of environmental access barriers in the home setting A lower projected raw cognition rating did not appear to be reflected as a predictor for discharge to inpatient rehab; however, a considerable number of patients in the RPG 1130 who were discharged to inpatient rehab had either cognition or communication deficits as reported by the clinicians and these appeared to be reflected in the projected raw cognition rating. Limitations: The sample size was small as data collection was slow and we did not meet the revised number of 200 patients. Funding was not available for this pilot project and data was collected manually by coordinators from each participating facility. There was no statistical analysis to determine if data was statistically significant and therefore no broad statements can be extrapolated. Finally, in the study design, gender was omitted and not collected. Discussion: Within this small sample of mild stroke patients, a large proportion (50%) were admitted to inpatient rehabilitation, with a median length of stay of <14 days. It appears that from the data collected, that these mild stroke patients were inclined to be admitted to inpatient rehabilitation if they had a lower motor rating, a co-morbidity of other physical deficits and environmental access barriers at home. It also appears that some patients were admitted to inpatient rehabilitation if they had cognitive or communication deficits, but this did not preclude them from going home. As the wait time for ambulatory care services could be up to 8 weeks and in- home CCAC services were most likely 5 As recommended by the OSN Stroke Reference Group recommendations to the Rehab/CCC Expert Panel Page14 14
minimal. This could indicate that some patients were admitted to inpatient rehabilitation due to lack of an appropriate level of service 6 in the community setting 7.This raises the concern of the walking wounded that are discharged home with potentially minimal to no follow up in the community. In conclusion, it is possible that many of the patients who went to inpatient rehab could be discharged to the community from the acute care setting with an appropriate level of rehabilitation service. In order to evaluate the effect of services and functional change in this setting, standardized assessment tools, such as the FIM would be needed as recommended in the Canadian Best Practice Recommendations 2010 8 and the Ontario Stroke Evaluation Report 2012. 9 15 6 as per recommendations of the OSN Provincial Stroke Reference Group to the Rehab/CCC Expert Panel 7 community setting refers to in home and ambulatory care settings 8 Canadian BPR for Stroke Care Update 2010: patients should be regularly assessed throughout their recovery. The acquired data can be used to identify resource needs across the stroke care system. 9 Ontario Stroke Evaluation Report 2012: Standardized measurement of functional independence and intensity of rehabilitation therapy provided across all rehab settings are needed to evaluate the appropriateness and effectiveness of rehabilitation. Page15 15