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Stroke is the second leading cause of death after ischemic heart disease; there were 6.
Aggressive rehabilitation is recommended after a stroke in order to enhance recovery and improve patient outcomes. In a retrospective cohort study of 1, stroke patients, better long-term outcomes were achieved in patients who underwent rehabilitation within 7 days after a stroke, compared to those who received therapy 1 month or more after a stroke. Of those patients who are medically appropriate for rehabilitation, it is necessary to determine the optimal location for short- and long-term rehabilitation in the post—acute care setting.
On an acute neurology service, disposition is one of the primary challenges managed from the moment a patient is admitted to the inpatient ward. Although there are multiple factors involved in the disposition decision-making process, it is important that acute stroke providers are aware of the benefits and drawbacks of each post-acute care option.
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Disposition options following acute hospitalization by level of acuity. Inpatient rehabilitation facilities IRFs have the benefit of close physician supervision, multidisciplinary care, and favorable patient outcomes proven through retrospective and prospective research.
One of the most important facts to consider when discharging a patient to an IRF is their need to provide the availability of physicians and nurses with specialized training or experience in medical rehabilitation for 24 hours a day 7 days per week.
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In addition to these medical professionals, licensed practitioners in occupational therapy Figure 4 , physical therapy Figure 5 , speech—language pathology Figure 6 , recreational therapy, and respiratory therapy are available. Other members of the multidisciplinary staff include a psychologist, social worker, vocational counselor, a prosthetics and orthotics department, and dietitians or nutritional counselors.
The IRF must employ enough staff members such that they are able to provide each patient with at least 3 hours of therapy daily and meet the rehabilitation medicine and rehabilitation nursing needs of the patients. Figure 2.
Physiatrist interviewing a stroke patient in the IRF. Daily physician care is a unique characteristic of a rehabilitation facility. Figure 3.
Two certified rehabilitation nurses and one physiatrist caring for the stroke patient in the IRF. Daily physician and hour nursing care is the multidisciplinary medical approach available in an IRF. Figure 4. A licensed occupational therapist applies a right upper extremity resting hand splint to a stroke patient in the IRF.
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In order for a patient to meet criteria for an IRF, their characteristics must relate to their needs for both medical management and rehabilitation programs. The patient must have substantial functional deficits as well as medical and nursing needs.
The patient must need close medical supervision by a physiatrist and a hour need for nurses skilled in rehabilitation. Physical therapists, occupational therapists, speech—language pathologists, and psychologists provide a medically coordinated program.
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The patient must have clear functional goals identified that are realistic in order to warrant admission. The medical and surgical comorbidities of a patient must be considered to be manageable in the rehabilitation hospital and sufficiently under control in order to permit simultaneous participation in the rehabilitation program. In most circumstances, the patient has a home and available family or care provider to ensure the likelihood of the patient to return home or to a community-based environment after completion of the rehabilitation course.
Figure 5. A licensed physical therapist provides moderate assistance to a stroke patient throughout ambulation training in the IRF. Most skilled nursing facilities SNFs provide fewer than 3 hours per day of therapy due to lack of a time requirement. In an SNF, the physician must provide general medical supervision of the patient. However, these visits are only required on admission, then once every 30 days, and only once every 60 days after the first 3 months. In regards to the rehabilitation program at the SNF, physicians do not necessarily manage therapy services, whereas this is routinely performed on a daily basis at an inpatient rehabilitation hospital.
However, there is no minimum therapy time requirement compared to an IRF. At an SNF, there is no requirement for interdisciplinary team conferences. Therapy providers may also determine independently of one another when therapy will end. Social services must be available by a social worker.
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In regards to the nursing program at the SNF, hour nursing staffing is not required, nor is certified rehabilitation nursing. Long-term acute care hospitals LTACHs provide care to patients with complex needs who require longer hospital stays and highly specialized medical and therapy services. LTACHs are designed for patients who need intense, extended care for more than 25 days. Therefore, the majority of patients admitted to LTACHs arrive directly from the intensive care unit of traditional acute hospitals.
LTACHs use a multidisciplinary team approach to meet the individual needs of patients.
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Figure 6. A licensed speech—language pathologist works in the IRF with a stroke patient to improve receptive and expressive language, memory recall, and word-finding ability. Home health and outpatient therapy are two options for patients who are medically and functionally appropriate to be discharged directly home from the acute care hospital with or without caregiver support.
The acute care physician and acute care therapy team must both come to the decision that discharge to home is a safe and appropriate disposition for the stroke patient. Home health therapy is chosen when the patient is medically or functionally unable to leave the home.
There has been a significant positive growth trend in the last 8 years for patients with minor strokes to be discharged home with home health therapies. These services can range from physical therapy to occupational therapy to speech—language pathology.
An important point to understand when considering this option for a patient is that this type of care is limited to a short amount of time in home, ranging on average 30 to 45 minutes per professional, two to three times weekly.
The other limitation is the minimal amount of equipment available for each professional to work with in the home. Outpatient therapy is chosen when the patient is able to leave the home and can transport to an outpatient therapy site.
Services are provided to the stroke patient in an outpatient facility. These services include physical therapy, occupational therapy, speech—language pathology, or vocational rehabilitation. The benefit of this option over home health therapy is the larger availability of equipment to work with that may be present in the outpatient facility. Also, the amount of service time provided is slightly more than that of home health, 45 to 60 minutes, two to three times weekly.
Table 1 provides a succinct guide to the different post—acute care options described above. In addition to discussing options with an acute therapist or case manager, it is essential to know the studied outcomes for the common rehabilitation options. The modified Rankin Scale mRS is a clinician-reported measure of global disability that has been widely applied for evaluating recovery from stroke and as a primary endpoint in randomized clinical trials of emerging acute stroke treatments.
It was determined that patients with stroke treated at an IRF were more than three times as likely as those at an SNF to return to the community. In addition, patients who were treated at an SNF were seven times more likely to return to the community compared to those who were discharged to traditional nursing homes without skilled therapy.
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As discussed, stroke patients who obtain medical and rehabilitation services at an IRF have a more favorable outcome compared to disposition to other facilities. This is likely due to the daily care of an in-house physician along with hour in-house certified rehabilitation nursing.
The daily care of a physician allows for continued medical care as the patient transitions from the acute to subacute setting.
This decreases delayed medical care that often occurs weeks after acute care discharge at the outpatient follow-up visit.
This also directly mitigates the lack of medical care that is not provided to a stroke patient who becomes lost to follow-up.
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There are a number of poststroke complications that may occur during the rehabilitation phase of stroke care Table 2. Disability is defined by a medical condition causing functional impairments, which lead to activity limitations and therefore create participation restriction.
When choosing the next step for a stroke patient, it is important to analyze the impairment level in order to project a rehabilitation goal. The goal for a patient is to progress from disability to ability in regards to an activity limitation.
The severity of a neurologic impairment and level of disability after a stroke are strong predictors for disposition after stroke. Another variable that may be used to determine stroke patient disposition is the acute hospitalization length of stay.
Patients with longer hospitalization periods were more likely to be discharged to an SNF than to any other location. Although functional scales are useful, medically complex patients are not always straightforward in regard to decisions for stroke patient disposition.
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In a retrospective analysis of a population-based stroke registry in France, it was found that patients with advanced age, anticoagulants at time of stroke, and dementia were less likely to return home or to an IRF and more likely to be discharged to an SNF. Overall, determining the optimal location for short and long-term rehabilitation in the post—acute care setting poses a challenge to acute care stroke providers.
The medical, functional, social, and economic status of the patient must all be analyzed in order to determine optimal stroke patient disposition. American Heart Association. Dallas: American Heart Association; Sowerbutt C. Multidisciplinary rehab in acute stroke: Canadian model sign of things to come?
Melvin JL. American Academy of Physical Medicine and Rehabilitation Task Force on medical inpatient rehabilitation criteria: standards for assessing medical appropriateness criteria for admitting patients to rehabilitation hospitals or units. Accessed September 2, RML Specialty Hospital.
Contemporary trends and predictors of postacute service use and routine discharge home after stroke. J Am Heart Assoc.
Outcomes validity and reliability of the modified Rankin Scale: implications for stroke clinical trials: a literature review and synthesis. Neurology ;84 suppl P1. Mor V. Better stroke outcomes in rehab hospitals. Hospital disposition after stroke in a national survey of acute cerebrovascular diseases in Israel. Poststroke disposition and associated factors in a population-based study: The Dijon Stroke Registry.
Post-stroke inpatient rehabilitation: II: predicting discharge disposition. Am J Phys Med Rehabil. January Stroke Patient Rehabilitation A guide to simplify stroke patient dispositions. Common Rehabilitation Disposition Options On an acute neurology service, disposition is one of the primary challenges managed from the moment a patient is admitted to the inpatient ward.