Assessing and managing rehabilitation needs of people with stroke in Australia Elizabeth Lynch Julie Luker Dominique Cadilhac Susan Hillier
Talk overview Stroke rehabilitation in Australia Pre-intervention: • How people assessed for stroke rehabilitation Intervention : Education vs multifaceted intervention Post-intervention: • Proportions of patients assessed • Criteria used in rehabilitation assessments • Barriers/enablers to improving practices Pathway to impact: • Dissemination • Stroke Foundation audit • Stroke Clinical Guidelines Lessons learned
Stroke in Australia Stroke affects 1 in 5 Australians 1 • Leading cause of disability in adults • One of leading causes of death Nearly 2/3 of people living with stroke in community need help for daily activities 2 1. The GBD 2016 Lifetime Risk of Stroke Collaborators, N Eng J Med 2018 2. Deloitte Access Economics 2013
Assessment for rehabilitation after stroke Marked inequity exists in access to stroke rehabilitation Global issue: In Canada, 37% patients with stroke need inpatient rehabilitation, 28% access inpatient rehabilitation 1 In Australia, assessments vary between reviewers 2 Country Proportions of patients assessed for rehabilitation Australia 49% (National Stroke Foundation 2013) Canada 58% (Willems et al, Arch Phys Med Rehabil, 2012) UK 85% (Royal College of Physicians SSNAP) USA 90% (Prvu-Bettger et al, Arch Phys Med Rehabil, 2013) 1. Willems et al, Healthcare Policy 2012 2. Kennedy et al, Arch Phys Med Rehabil , 2012
Stroke rehabilitation pathway
Stroke rehabilitation pathway - what can go wrong? Variable referral Stroke unit rates 27-73%
Stroke rehabilitation pathway - what can go wrong? Variable referral Stroke unit rates 27-73% Severe stroke Mild stroke
Stroke rehabilitation pathway - what can go wrong? Variable referral Stroke unit rates 27-73% Severe stroke Mild stroke Family advocacy Invalid criteria Assessor opinion Current rate 45%
Stroke rehabilitation pathway - what can go wrong? Variable referral Stroke unit rates 27-73% Severe stroke Mild stroke Family advocacy Invalid criteria Assessor opinion Current rate 45% Rehabilitation Relationship with centre priorities acute hospital
Assessment for Rehabilitation Tool Each person should receive the right rehabilitation in the right place at the right time Developed in 2011 • Existing literature • Survey of clinical practice • Expert working group • Pilot tested Patient-centred, evidence- based decision-making tool Released in December 2012
Domain Current level Rehab Able to be of function indicated managed at (y/n) home Swallowing Hydration, nutrition Continence Mobility – transfers, gait Activities of daily living Eating and drinking Communication Cognition, insight Level of alertness, engagement Vision, sensory systems, perception Behaviour Emotional, psychological Specialty needs eg IV, PEG
Participation (consistent with Role/s pre-stroke Need for ICF framework) rehabilitation/intervention Y/N? If Y, plan? Domestic Vocational Recreational Social Environment Pre-stroke (note barriers and Need for intervention Y/N? facilitators) If Y, plan? Home Extended Rehabilitation is indicated for every person with stroke unless : 1. Palliation 2. Persistently non-responsive (coma) 3. Refused 4. Full recovery www.australianstrokecoalition.com.au
How were patients being assessed for rehabilitation on acute stroke units? Observations • Observed team meetings at 2 stroke units over 4 weeks • Field notes taken, medical records reviewed • Inductive content analysis by 2 reviewers
Observations: How rehabilitation discussed, how referrals affected 24 team meetings observed (5 case conferences at each stroke unit), providing data on 64 patients Rehab mentioned (n=50, 78%) For rehab Not for referral referral ( n=47, 94%) (n=3) Residential Patient Full care refused recovery (n=1) (n=1) (n=1)
Observations: How rehabilitation discussed, how referrals affected 24 team meetings observed (5 case conferences at each stroke unit), providing data on 64 patients Rehab mentioned Rehab not mentioned (n=50, 78%) (n=14, 22%) For rehab Not for Not referred referral referral (n=14) ( n=47, 94%) (n=3) Residential Patient Plan Home, Residential Full Palliation care refused unclear no rehab care recovery (n=2) (n=1) (n=1) (n=1) (n=4) (n=1) (n=7)
Observations: How rehabilitation discussed, how referrals affected 24 team meetings observed (5 case conferences at each stroke unit), providing data on 64 patients Rehab mentioned Rehab not mentioned (n=50, 78%) (n=14, 22%) For rehab Not for Not referred referral referral (n=14) ( n=47, 94%) (n=3) Residential Patient Plan Home, Residential Full Palliation care refused unclear no rehab care recovery (n=2) (n=1) (n=1) (n=1) (n=4) (n=1) (n=7) Note: effect of non-English speaking background
Observations: factors affecting whether rehabilitation discussed Rehabilitation not Rehabilitation Rehabilitation not discussed unless consistently discussed family request discussed referral Reduced alertness, Obvious symptoms, Very mild stroke- alert, improving speech related symptoms or severe hemiplegia, and/or mobility none apparent dysphagia Anticipated palliation Anticipated discharge Anticipated discharge home or low level or discharge to high home residential care level residential care Active input by PT, OT Discharged from/ not SP and PT ‘monitor’ and or SP function, no OT input assessed by PT, OT, SP
Observations: factors affecting whether rehabilitation discussed Rehabilitation not Rehabilitation Rehabilitation not discussed unless consistently discussed family request discussed referral Reduced alertness, Obvious symptoms, Very mild stroke- alert, improving speech related symptoms or severe hemiplegia, and/or mobility none apparent dysphagia Anticipated palliation Anticipated discharge Anticipated discharge home or low level or discharge to high home residential care level residential care Active input by PT, OT Discharged from/ not SP and PT ‘monitor’ and or SP function, no OT input assessed by PT, OT, SP
Observations: factors affecting whether rehabilitation discussed Rehabilitation not Rehabilitation Rehabilitation not discussed unless consistently discussed family request discussed referral Reduced alertness, Obvious symptoms, Very mild stroke- alert, improving speech related symptoms or severe hemiplegia, and/or mobility none apparent dysphagia Anticipated palliation Anticipated discharge Anticipated discharge home or low level or discharge to high home residential care level residential care Active input by PT, OT Discharged from/ not SP and PT ‘monitor’ and or SP function, no OT input assessed by PT, OT, SP
Observations: factors affecting whether rehabilitation discussed Rehabilitation not Rehabilitation Rehabilitation not discussed unless consistently discussed family request discussed referral Reduced alertness, Obvious symptoms, Very mild stroke- alert, improving speech related symptoms or severe hemiplegia, and/or mobility none apparent dysphagia Anticipated palliation Anticipated discharge Anticipated discharge home or low level or discharge to high home residential care level residential care Active input by PT, OT Discharged from/ not SP and PT ‘monitor’ and or SP function, no OT input assessed by PT, OT, SP
Observations: factors affecting whether rehabilitation discussed Rehabilitation not Rehabilitation Rehabilitation not discussed unless consistently discussed family request discussed referral Reduced alertness, Obvious symptoms, Very mild stroke- alert, improving speech related symptoms or severe hemiplegia, and/or mobility none apparent dysphagia Anticipated palliation Anticipated discharge Anticipated discharge home or low level or discharge to high home residential care level residential care Active input by PT, OT Discharged from/ not SP and PT ‘monitor’ and or SP function, no OT input assessed by PT, OT, SP
Observations: factors affecting whether rehabilitation discussed Rehabilitation not Rehabilitation Rehabilitation not discussed unless consistently discussed family request discussed referral Reduced alertness, Obvious symptoms, Very mild stroke- alert, improving speech related symptoms or severe hemiplegia, and/or mobility none apparent dysphagia Anticipated palliation Anticipated discharge Anticipated discharge home or low level or discharge to high home residential care level residential care Active input by PT, OT Discharged from/ not SP and PT ‘monitor’ and or SP function, no OT input assessed by PT, OT, SP
Observations: factors affecting whether rehabilitation discussed Rehabilitation not Rehabilitation Rehabilitation not discussed unless consistently discussed family request discussed referral Reduced alertness, Obvious symptoms, Very mild stroke- alert, improving speech related symptoms or severe hemiplegia, and/or mobility none apparent dysphagia Anticipated palliation Anticipated discharge Anticipated discharge home or low level or discharge to high home residential care level residential care Active input by PT, OT Discharged from/ not SP and PT ‘monitor’ and or SP function, no OT input assessed by PT, OT, SP
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