Stroke Rehab Across the Continuum of Care in Quinte Region Adrienne Bell Smith Manager of Rehab Therapies QHC Karen Brown Manger Client Services, Hospital Access South East CCAC
Disclosure of Potential for Conflict of Interest Adrienne Bell-Smith, MHSc(SLP), Reg. CASLPO Manager Rehab Therapies, Quinte Health Care Karen Brown RN, BScN Manager Client Services Hospital, SE CCAC Stroke Rehabilitation across the Continuum of Care FINANCIAL DISCLOSURE: Support provided by the Stroke Network of Southeastern Ontario Other:None
Stroke Rehabilitation Complex array of deficits and potential complications = Complexity of Rehabilitation Weakness Spasticity Dyspraxia Perceptual Disorder Cognitive Impairment Dysphagia Aphasia Dysarthria Mood/Depression Mobility Personal Hygiene Communication Toileting Dressing Nutrition Social Skills Problem Solving/Decision Making
Stroke Rehab Plan of Care Rehabilitation of functional and cognitive status Training of family and caregivers Procurement of adaptive equipment Environmental modifications Integration into home roles Integration into community settings Social support / coping Movement along the continuum of care
Rehabilitation Settings Across the Continuum ACUTE CARE REHAB CCAC REHAB DAY HOSPITAL CCC
REHABILITATION IN ACUTE CARE GOALS: Prevention of Medical Complications Prevention of Deconditioning and Contractures Training of New Skills METHODS: Dysphagia screen/assessment/management Early Mobilization/Positioning Cognitive Assessment Care Planning Patient/Family Education Discharge Planning
QHC Medicine: Services Available BGH TMH PEC NH Physiotherapist 2 1 0.5 0.2 Occupational Therapists 1 0.4 O O Speech Therapists 1 0 5 days a week/8 hr days WEEKENDS/HOLIDAY: Physiotherapy available in BGH on Sat/Sun for patients flagged as possible weekend discharges BEST PRACTICE RECOMMENDATION: All stroke patients are admitted to an acute stroke unit. 78% admitted to Q5 at QHC
IN PATIENT POST ACUTE REHABILITATION Peak neurological recovery from stroke occurs within the first one to three months. Survivors of a moderate stroke will receive a minimum of one hour of direct therapy time for each relevant core therapy, with an individualized treatment plan, for a minimum of five days a week, by the interprofessional stroke team based on individual need and tolerance. (Evidence Level 3)
In Patient Rehab Unit Sills 3 BGH 18 bed unit Physician, nursing, physiotherapy, occupational therapy, speech language pathology, rehab assistants FAST TRACK: Patients with an established discharge plan and goals that can be met in under 2 weeks. 2010/11 Fiscal Year 76 Strokes Admitted to In Patient Rehab Days Waiting 0.3 Avg Length of Stay = 37.9 Average Admission FIM = 75 Average Discharge FIM = 102
In Patient Rehab Unit Sills 3 BGH BEST PRACTICE RECOMMENDATION: Timely transfer of appropriate patients from acute facilities to rehabilitation (Ischemic strokes by day 5 and Hemorrhagic strokes by day 7) 25 20 15 10 5 Stroke Onset Days (AVG) On Admission to Rehab 2011-12 Average = 14 days 0 2011-2012 Q4 2011-2012 Q3 2011-2012 Q2 2011-2012 Q1
In Patient Rehab Unit Sills 3 BGH 1) Medically stable CRITERIA (5) + READINESS MRP identifies patient no longer requires acute care Cause of primary diagnosis/reason for admission explored with medical investigations completed or in process Secondary prevention/medication plan initiated Comorbid medical conditions managed/stable 2) Patient has rehab goals 3) Patient demonstrates improvement in function over time 4) Patient/SDM agrees to goals and is willing to participate in rehab 5)Patient has cognitive ability to participate in and benefit from program READINESS: Minimum 60 min sitting tolerance and ability to participate in at least 2X 30 minutes of therapeutic interventions per day
Slow Stream Rehab Severe Stroke: Survivors of a severe stroke who are Rehab Ready will receive the frequency and duration of therapy that can be tolerated; the interprofessional team will increase the frequency and duration as tolerance improves to a minimum target of one hour of direct therapy time for each relevant core therapy, with an individualized treatment plan, for a minimum of five days per week, by the interprofessional stroke team based on individual need and tolerance. (Evidence Level 1)
Slow Stream Rehab (CCC) Sills 4 CCC SSR is one of 3 programs offered on Sills 4 (in addition to CCC and Palliative Care) Same 5 Criteria as In Patient Rehab Readiness: Minimum 30 min sitting tolerance a able to participate in at least 2X 15 minute therapeutic interventions/day.
Referral Process Rehab/SSR Interprofeesional team determines patient requires InPatient Rehab/SSR to achieve rehabilitation goals (vs. Rehab Day Hospital or Home Care) Physician writes order for discharge Completion of referral by Patient Flow Coordinator Referral reviewed by admitting floor and sending floor is notified of acceptance
Rehab Day Hospital Mild Stroke: Stroke survivors discharged to the community will be provided with ambulatory services for one hour of each appropriate therapy, two to five times per week, as tolerated by the patient and as indicated by patient need. (Evidence Level 3)
Rehab Day Hospital BGH Sills 2 PT, OT, SLP, RN, Rec Therapy, Nursing, Social Work 2 3 up to 5 visits per week Interprofessional team approach Focus on functional performance, independence, safety, supportive discharge from hospital, community reintegration 1 3 week waitlist
Community Based Enhanced Therapy improving outcomes by providing faster improvement in functional ability with return to the community coupled with decreased health system costs including fewer hospital readmissions. South East Region: 66% of referrals come from Rehab beds 31% of referrals from acute care beds 3% from other Quinte Health Care estimates: 85% from Rehab, 15% from Acute
Eligibility Eligibility Criteria for Enhanced Services Clients will: Be 16 years of age or older and live in Southeastern Ontario Have had a recent stroke or a diagnosis of stroke Are eligible for CCAC follow up therapy at home or in a residential care facility or LTCH
CCAC Guidelines for Enhanced Therapy
In Home Therapy Service First 4 weeks: Up to: 2 extra visits/wk of OT and PT 1 extra visit/wk of SLP and SW Weeks 4 8: Up to: 1 extra visit/wk of OT and PT 1 extra visit/2wks of SLP and SW Enhanced Therapy Services funded for 60 days only
Enhanced vs Regular In Home Therapy CCAC Baseline Services vs Enhanced Services OT Weekly for 8 weeks Up to: 2 extra visits/wk of OT CM could therefore authorize in the service plan up to 3 visits per week for the first 4 weeks PT Weekly for 8 weeks Up to: 2 extra visits/wk of PT CM could therefore authorize in the service plan up to 3 visits per week for the first 4 weeks SW Social Work is normally as required Up to: 1 extra visit/wk of SW CM could therefore authorize in the service plan up to weekly visits for the first 4 weeks SLP Weekly for the first 4 weeks and bi weekly for the next 4 weeks Up to: 1 extra visit/wk of SLP CM could therefore authorize in the service plan up to 2 visits per week for the first 4 weeks
Discharge Link Meeting This meeting occurs between the hospital inpatient occupational therapist (OT) and the CCAC OT prior to discharge. (Physiotherapists and Speech Language Pathologists will continue to exchange treatment information in the usual way). Clients may participate in a Discharge Link meeting. The purposes of the Discharge Link meeting are: To improve the communication of client goals, therapy plans and treatment techniques through a face to face meeting of the inpatient OT and the community OT. To increase client involvement by allowing the client to be part of the process.
Hospital Case Manager Will: Determine eligibility for in home services Coordinate discharge link meeting Negotiate initial in home service plan Authorize first 4 weeks of service provision Communicate with community service providers Facilitate transition to community case manager for follow up Complete required documentation
Community Case Manager Will: Receive therapy reports at 2 week point in service plan Provide Home Visit reassessment of needs when required Be responsible for authorizing the second 4 week service plan Complete required documentation
Wait Times and Prioritization Clients eligible for enhanced therapy services for stroke rehab are considered VERY HIGH priority and therefore must be seen in their home within 5 calendar days, no matter where in the South East they live.
Success Stories QHC Rehab Data Decrease in rehab LOS from 54 to 41 days Increase from 15% to 39% in those discharged home with service provision Increase from 72% to 88% in those discharged back home positive experience with discharge link meeting Increase in understanding re needs related to SW Increasing dialogue and understanding between sectors