STROKE REHABILITATIONREBUILDING A LIFE

Marla Rose, Speech Language Pathologist

Trinity Hospital

OBJECTIVES

Discuss the multiple levels of rehabilitation Therapeutic services provided from acute care to

home. Therapeutic rationale for intervention and for

discharge planning

WHO ARE WE TALKING ABOUT

In UNITED STATES, approximately 795,000 people suffer a stroke each year.

Approximately three-quarters of all strokes occur in people over the age of 65.

Approximately one fourth of strokes occur in people under the age of 65.

TRINITY HOSPITAL - 2011

165 admitted with stroke as primary diagnosis 83% Ischemic 11% Intracerebral hemorrahage 5% Subarachnoid hemorrhage

Average age: 70.5 years

Discharge disposition 42% Home 23% Inpatient rehab 13% SNF 7% Expired

REBUILDING A LIFE

Stroke is the leading cause of serious, long-term disability in the United States.

ROAD TO RECOVERY

RECOVERY STATISTICS

Much variability in statistics

Most improvement noted in the first 6 months

5% show continued improvement up to 12 months

47 – 76% achieve partial or total independence in ADLs

MULTIPLE LEVELS OF REHABILITATION

Home – Independent

Home + Outpatient tx

Home + Home Care

Skilled Nursing Facility

Inpatient Rehab

Acute Care

FACTORS PREDICTING ADL OUTCOMES

Advanced age Comorbidities Myocardial infarction Diabetes mellitus Severe stroke Severe weakness Poor sitting balance

Visuo-spatial deficits Mental changes Incontinence Low initial ADL

scores Delay in initiating

rehabilitation following onset

REHABILITATION TEAM

Patient and family Physicians Physical Therapist Occupational

Therapist Speech-language

Pathologist

Nurses Dietician Social Worker Orthotist Mental Health Insurance Company Community

Resources

ACUTE CAREACUTE LOS: 4.6 DAYS

PT/OT: Diagnostic intervention Range of motion Introduce activity/exercise Assess potential for more aggressive

intervention Provide patient/caregiver education Assist with discharge planning

ACUTE CAREACUTE LOS: 4.6 DAYS

SLP Diagnostic intervention Assess cognitive - communication skills Assess for potential to participate in more

aggressive intervention Provide patient/family education Assist with discharge planning

ACUTE CARE

SLP Assess swallowing and make recommendations Monitor swallowing function Assess for potential to participate in structured

intervention Provide patient/family education Assist with discharge planning

ACUTE DISCHARGE PLANNING

Home with outpatient therapy

Home with Home Health Therapy

Inpatient rehab

Skilled nursing facility

TEAM members: patient and family; physicians; inpatient rehab medical director; case managers; social workers; therapists; 3rd party payer.

REHABILITATION THEORY

Evidence from clinical trial supports early initiation of therapy.

Early improvement (3 – 6 months): Resolution of local edema Resorption of local toxins Improvement of local circulation Recovery of partially damaged neurons

REHABILITATION THEORY

Ongoing improvement (for many months) Neuroplasticity – the ability of the brain to

modify its structural and functional organization New synaptic connections Activating latent functional pathways Utilization of redundant neural pathways

REHABILITATION THEORY

To influence brain re-organization we must DO SOMETHING to facilitate the lost skill. Therapy exercise must promote USE rather than non-use.

Repetitive, skilled, functional movement is

beneficial in facilitation of brain re-organization.

MEDICARE’S EXPECTATION

Therapeutic services provided require the skilled services of a qualified therapist.

The patient’s condition will improve significantly in a reasonable and generally predictable length of time.

Therapy results in recovery or improvement in function.

INPATIENT REHABTrinity Hospital – St. Joseph’s Campus

INPATIENT REHABWHAT YOU NEED TO KNOW

3 hour rule

Must benefit from at least 2 therapy disciplines

Length of stay Determined by Medicare Admit severity Co-morbidities

Goal is to discharge patients home

ADMIT SEVERITY: HOW IS THIS

DETERMINED?

Functional Independence Measure: FIM

National rating scale, 1 – 7 7 = Independent 1 = Total Assistance

Reflects the burden of care; how much assistance is required for the patient to carry out ADLs.

FIM

Eating Grooming Bathing Upper body dressing Lower body dressing Toileting Bladder

Management Bowel Management Bed to chair transfer

Toilet Transfer Tub/shower transfer Locomotion Stairs Comprehension Expression Social Interaction Problem solving Memory

INPATIENT REHABHOW IS IT DIFFERENT

Therapy intensity

Mandatory participation

Therapy staff

Social Worker

Medical director – visits patients daily

Nursing staff and the scope of their responsibilities

MEDICAL COMPLICATIONS

Pulmonary aspiration, pneumonia – 40% Urinary tract infection – 40% Depression – 30% Musculoskeletal pain – 30% Falls – 25% Malnutrition – 16% Venous thromboembolism 6% Pressure ulcer – 3%

NURSING STAFF

They’re not ONLY nurses

They’re NURSE THERAPISTS

INPATIENT REHAB NURSING STAFF

Daily, frequent contact with patients Reinforce therapy strategies Provide frequent opportunities to practice

what patients are learning in therapy They MUST know patients’ level of

functioning in 16 FIM areas Current level Where they are progressing Where they are not progressing How their level of functioning influences the

discharge plans.

INPATIENT REHAB OUTCOMES

2011 2007 # of stroke patients 51 72 Average Age 72 73 ALOS (days) 13 14 D/C Home 80% 74% D/C SNF 16% 17% Ave FIM gain points 28 22

(target: 28 points)

PHYSICAL THERAPY

Exercises to address the sensory-motor physiology

Apply the physiological gains to functional ADLs

OCCUPATIONAL THERAPY

Exercises to address the sensory-motor physiology

Apply the physiological gains to functional ADLs

SPEECH-LANGUAGE PATHOLOGY

Exercises to address the sensory-motor physiology of swallowing

Apply the physiological gains to functional swallow

SPEECH-LANGUAGE PATHOLOGY

Exercises to address neurological processing and/or physiology for communication skills

Apply gains to functional communication interactions

SKILLED NURSING FACILITY

Scenario #1 Patient transferred from acute care immediately

following stroke.

Scenario #2 Patient transferred from inpatient rehab with

Good progress made and positive prognosis Poor progress made and guarded prognosis

SKILLED NURSING FACILITY

Philosophy of brain re-organization - same Rate of progress will likely be slower Intensity of therapy will likely be less Possibly less daily activity Nursing staff ‘hands-on’ will likely be less Primary physician will not see patient daily Eventually may begin to include exercises

designed to develop compensatory skills

HOME WITH HOME CARE

Scenario # 1 Patient discharged from inpatient rehab with

recommendations to continue therapy.

Scenario #2 Patient discharged from acute care with

recommendations for therapy.

HOME WITH HOME CARE

Philosophy of brain re-organization - same Rate of progress may possibly be slower Intensity of therapy will likely be less Possibly less daily activity Advantage of addressing ADLs in their home Motivation Nurse is available on limited basis Eventually design therapy goals and exercises

to address work and social needs Eventually begin to include exercises designed

to develop compensatory skills HOME BOUND

HOME WITH OUTPATIENT THERAPY Scenario # 1

Discharged home from acute with recommendations for outpatient therapy.

Scenario #2 Discharged home from inpatient rehab with

recommendations for outpatient therapy. Scenario #3

Discharged home from SNF with recommendations for outpatient therapy.

Scenario #4 Discharged from Home Care services with

recommendations for outpatient therapy.

HOME WITH OUTPATIENT THERAPY

Philosophy of brain re-organization - same Rate of progress will eventually be slower Intensity of therapy will likely be less Possibly less daily activity Motivation Eventually design therapy goals and

exercises to address work and social needs in addition to ADLs

Eventually begin to include exercises designed to develop compensatory skills

THROUGH ALL LEVELS OF REHABILITATION

Patient goals

Medicare/3rd party payer expectations

Neuroplasticity theory

Target actual functional use BEFORE compensatory training