Stroke Pathways Taskforce Joseph Burris, MD Director, Stroke Rehabilitation Missouri Stroke Program/Rusk Rehabilitation Center University of Missouri Columbia, MO
Stroke Pathways Taskforce Joseph Burris, MD Director, Stroke Rehabilitation Missouri Stroke Program/Rusk Rehabilitation Center University of Missouri Columbia,
o Stroke recurrence risk factorso Secondary stroke prophylaxiso Medical comorbidities and effects on post acute care needso DVT prophylaxiso Cognition/communicationo Dysphagiao Nutrition o Mobility/self careo Bowel/bladder functiono Skin integrity o Caregiver availabilityo Patient/caregiver educationo Depression/mental health screeno Spasticityo Durable medical equipment/orthotic needs
Recommendation regarding transition to appropriate level of post acute care and follow up with physiatry/rehabilitation physician for future stroke rehabilitation needs
Transition to appropriate level of post acute care
Burris, Joseph E.
nguyen: Also, regarding discharge from acute inpatient rehabilitation, I think we need to make it clear that discharge is dependent on patient meeting functional goals AND that immediate medical needs have been resolved with plan for follow up. I bring this up because it seems at times that I have a medical issue that requires extra days despite the patient meeting impatient goals, and I get push-back from payers about it.
Burris, Joseph E.
nguyen: Will need to operationalized so that it is less wordy and more algorithmic in action – perhaps a flowchart to operationalize, then a click off or checklist
Burris, Joseph E.
nguyen: Need nutritional/dietary support for acute and post-acute institutional based for optimizing nutrition and caloric needs
Burris, Joseph E.
put in as nutrition assessment
Burris, Joseph E.
harvey: But additional findings on neurological examination not well measured in NIH might be included such as fine motor hand, manual testing (motricity index?), sitting balance and standing balance.
Burris, Joseph E.
harvey:
Burris, Joseph E.
We might want to discuss which depression screens might be appropriate.
Burris, Joseph E.
harvey: At my center communication may be assessed, but cognition is usually not assessed in detail. My residents will often to a mini-mental status, but we might want to suggest screening options for this.
Burris, Joseph E.
harvey: “Follow up with physiatry or physician with expertise in neurological rehabilitation” might be better wording. This should be used consistently throughout the document.
Burris, Joseph E.
harvey: In acute care, should “ongoing medical treatments” be added? For example, IV antibiotics, Dialysis, etc.
Burris, Joseph E.
added as a bullet point
Burris, Joseph E.
Just recommend adding to the RED section another bullet: “Patient, family and/or caregiver education and training in patient care needs” This should have the blue and green star too. If you all agree of course. I just worry there is no more room on the slide!
Burris, Joseph E.
education and training comment added to family/caregiver status, and slide 2 reflects changes for post acute levels of care
Burris, Joseph E.
nguyen: Will need to operationalized so that it is less wordy and more algorithmic in action – perhaps a flowchart to operationalize, then a click off or checklist
Burris, Joseph E.
agree, this document needs to be turned in to a flow diagram by someone with these skills-- will not be me :)
Burris, Joseph E.
algorithm embedded from last bullet point slide 1 to top bulled points for each level of post acute care in slide 2--hours of therapy for IRF and SNF, medical instability for LTAC
Burris, Joseph E.
nguyen: Acute: Include in the durable medical equipment needs should be orthosis evaluation for function and to minimize decline.
Burris, Joseph E.
this is included specifically in the DME bullet point
Joseph Burris
this is included specifically in the DME bullet point
Joseph Burris
RBS: Was the reference for the NIHSS prognosis levels the TOAST trial? If so, we may want to shift the category boundaries to the numbers they used - good recovery <7; variable recovery 7-15; likelihood of severe disability (sounds less bleak than ‘poor’); 16 or greater. These were 3 month recovery estimates, which makes them particularly applicable to the inpatient consult rehabilitation physician helping to direct the patient to the next level of care. Trial abstract is below for your review.burris: changed to reflect TOAST criteria if task force agrees
AAPM&R -- Management of Stroke RehabilitationPost Acute Institutional Based
o Inpatient Rehabilitation Facility (IRF): Coordinated, interdisciplinary rehabilitation team with expertise in stroke rehabilitation, including: physiatrist/rehabilitation physician;
physical, occupational, and speech therapy; psychology; rehabilitation nursing; case manager/social worker. May also include recreational therapy, vocational rehabilitation, neuropsychology
Requires at least 2 of 3: PT/OT/ST Sufficient medical stability to perform at least 3 hours of therapy at least 5 days per week or 15 hours of therapy over 7 days per week under
special circumstances (e.g. dialysis) Physiatrist/rehabilitation physician oversight 3-7 days per week for evaluation/intervention of medical/rehabilitation management issues Including items highlighted
• Ability to perform at least 1-3 hours of therapy 5 days per week
• Physiatry/rehabilitation attending/consultant for recommendations specific to stroke rehabilitation needs
• Including items highlighted
• Long Term Care Hospital(LTCH):• Medical treatment issues
supersede rehabilitation needs at another level of post acute care
• 3 day ICU stay during acute hospitalization required
• Physiatry consultant for recommendations specific to stroke rehabilitation needs:
• Including items highlighted
• Nursing facility:• Patient/caregivers unable to meet needs for community discharge• For acute stroke, IRF/SNF benefits may be available• Formal/restorative therapy needs, as indicated• Including items highlighted **
The patient with stroke rehabilitation needs will best benefit from evaluation and management in the following post acute care setting(s):
Recommendation for transition to appropriate level of post acute care and follow up with physiatry/rehabilitation physician for stroke rehabilitation needs, as indicated
Goal of community discharge Education and training for patient/caregivers** Cognition/communication** Bowel/bladder function* Skin integrity* Mobility/self care (ADL)** Medical care adjustments for comorbid conditions** Dysphagia/nutrition needs for elevated
malnutrition/dehydration risk** Pain management** Spasticity/hypertonicity management** Adjustment and mood disorders, including psychology
consultation** Durable medical equipment** Orthotic and assistive devices** Assessment of post acute rehabilitation community and
financial resources** Consultation and follow up care with primary physician,
and neurology/neurosurgery/other specialties, as indicated**
Burris, Joseph E.
nguyen: Post Acute Institutional Based: Since we are asking for everything that we feel is right for care, we should include home evaluation. As IRFs are going to receive sicker and sicker patients, consideration for medical co-management should be addressed.
Burris, Joseph E.
do we need this as a bullet point, or is it wrapped in the IRF stay already??
Burris, Joseph E.
nguyen: Need nutritional/dietary support for acute and post-acute institutional based for optimizing nutrition and caloric needs
Burris, Joseph E.
added under dysphagia bullet point
Burris, Joseph E.
harvey: For post-acute care, if we are following Medicare rules (which it seems we are) then 15 hours over 7 days is usually appropriate “when specific medical circumstances require it (e.g. dialysis)”
Burris, Joseph E.
added in bullet point
Burris, Joseph E.
harvey: Can I assume that “goal of community discharge” in IRF is the long-term plan? Many patients go to SNF for a period after IRF before return home. I agree that in most cases if long-term plan is SNF, that IRF may not be appropriate.
Burris, Joseph E.
good to discuss, do we leave the "goal of community discharge even if patients are going to snf? I believe average rate if 70% home d/c, 30% to snf
Burris, Joseph E.
harvey: In my area SNF and nursing facility are the same and there is no such thing as “subacute” . So our SNF’s provide long-term nursing care or rehabilitation or both (usually separate units in same SNF). So we may need to tweak the terminology to match these differences. Perhaps we should call it “SNF with rehabilitation program”
Burris, Joseph E.
subacute reference removed from slide 2
Burris, Joseph E.
harvey: Just recommend adding to the RED section another bullet: “Patient, family and/or caregiver education and training in patient care needs” This should have the blue and green star too. If you all agree of course. I just worry there is no more room on the slide!
Burris, Joseph E.
bullet point 2 under IRF changed to reflect needs
Burris, Joseph E.
bullet point 2 under IRF changed to reflect needs
Burris, Joseph E.
nguyen: consideration for medical co-management should be addressed.
Burris, Joseph E.
added to bullet point with follow up care. now reads consultation adn follow up care...
Burris, Joseph E.
nguyen: Since we are asking for everything that we feel is right for care, we should include home evaluation.
Burris, Joseph E.
agree but does this deserve its own bullet point? maybe we should consider since thv, loa, and home evaluations may be attacked more by insurers...
Burris, Joseph E.
agree but does this deserve its own bullet point? maybe we should consider since thv, loa, and home evaluations may be attacked more by insurers...
Burris, Joseph E.
nguyen: Need nutritional/dietary support for acute and post-acute institutional based for optimizing nutrition and caloric needs. Need for post-acute community based for supplements, lifestyle modifications.
Burris, Joseph E.
see dysphagia/nutrition bullet point, also covers with ** to post acute non institutional based
Burris, Joseph E.
nguyen: Shoulder subluxation/pain assessment and management should be included at all stages acute, post acute institution and post acute community.
Burris, Joseph E.
while this is important, I don't think it needs a specific bullet point, can be put in the pain management bullet point
Joseph Burris
RBS: On the blue slide: Are patients ever sent to custodial SNF directly from acute care after a new stroke? Don’t they all start in SNF active rehab (because Medicare will pay for this after hospitalization) and then either go home or get converted to chronic care after a few weeks? I wonder if we can delete the custodial option from the slide as one that is rarely used. burris: intent was to present options beyond acute stroke consultation since this is a reference document for venues of acute stroke rehab and follow up needs. In Missouri, medicaid patients can receive inpt rehab or go to long term care, but they do not get snf benefits even after acute stroke
Joseph Burris
RBS: 3 day qualifying ICU stay to the LTACH box, since that rule starts in October, 2015. I don’t see a need to add hospital centric requirements such as the LTACH avge LOS of >25 days and the limit on patients admitted to LTACH from any one acute hospital, or the IRF dx criteria. burris: bullet point added for 3 day, but is this required for non-medicare patients? if not then we may want to clarify as medicare guideline specifically
Joseph Burris
I would suggest in the IRF box using the term ‘rehabilitation physician’ rather than physiatrist – I believe there are still many IRFs with a co-management model involving physiatrists as consultants and hospitalists as attendings. Each type of doctor sees the patient 3x/wk.burris: rehabilitation physician added to second bullet point mentioning physiatry, and oversight frequency reduced from 5 to 3 days as minimum visit, maximum of 7 days left in the bullet point
Joseph Burris
RBS: I think the bullet points in red in the IRF blue box should be listed separately in their own box on that page since they are the same at each of the inpatient levels of care.burris: I agree. I need someone with better visual skills to turn this document into one that has better visual flow. requrest consultant for this. I suggest red bullet points central as a hub with spokes of postacute venues surrounding with two way arrows connecting the boxes.
AAPM&R -- Management of Stroke RehabilitationPost Acute Community Based
Home Health:• Patient will be considered “homebound”• Patient/family will benefit from interventions specific to their home environment• Inability to arrange logistics for attendance in an outpatient treatment program due to patient tolerance or program availability• Physical, occupational, and speech therapy, social worker, as indicated• Nursing/aide, as indicated• Including items *
• Outpatient Therapy: Physical,
occupational, and speech therapy as indicated
Interdisciplinary outpatient programs, as available/indicated
(Rehabilitation) Psychology, as indicated
Neuropsychologic testing, as indicated
Vocational rehabilitation, as indicated
Driving evaluation ,as indicated
Including items *
o Hospice and Palliative Care: Poor prognosis of
recovery (<6months life expectancy)
Goal of appropriate end of life care
Including items highlighted
The patient with stroke rehabilitation needs will best benefit from evaluation and management in the following post acute care setting:
Recommendation for transition to appropriate level of post acute care and follow up with physiatry/rehabilitation physician for stroke rehabilitation needs, as indicated
• Education for patient/caregivers**• Cognition/communication**• Bowel/bladder function*• Skin integrity*• Mobility/self care (ADL)**• Medical care adjustments for comorbid
conditions**• Dysphagia/nutrition needs for elevated
malnutrition/dehydration risk**• Pain management**• Spasticity/hypertonicity management**• Adjustment and mood disorders, including
psychology consultation**• Durable medical equipment**• Orthotic and assistive devices** • Assessment of post acute rehabilitation community
and financial resources**• Consultation and follow up care with primary
physician, and neurology/neurosurgery/other specialties, as indicated**
Burris, Joseph E.
nguyen: Should include topics on community reintegration to include vocational rehab, driving evaluation, family or couples counseling on role adjustment and responsibilities, cooking, financial management.
Burris, Joseph E.
vocational and driving added, tried to hit counseling with the bullet point "rehabilitation psychology."
Burris, Joseph E.
nguyen: Need for post-acute community based for supplements, lifestyle modifications.
Burris, Joseph E.
yes but how to state succinctly?
Burris, Joseph E.
harvey: Home health should include – the patient cannot easily be transported in and out of home. In addition, can I assume tolerance means inability to tolerate the process of transportation to an outpatient center?
Burris, Joseph E.
worded as "patient tolerance" but maybe need to be more explicit
Burris, Joseph E.
harvey: 5. Outpatient therapy: Should include “vocational rehabilitation as indicated”.
Burris, Joseph E.
added as bullet point
Burris, Joseph E.
harvey: 6. Outpatient therapy: should include “interdisciplinary outpatient rehabilitation programs as available and appropriate”
Burris, Joseph E.
added as bullet point
Burris, Joseph E.
nguyen: Should include topics on community reintegration to include vocational rehab, driving evaluation, family or couples counseling on role adjustment and responsibilities, cooking, financial management.
Burris, Joseph E.
these are added but may not have quite this specificity in current version...do we need to be more specific here??
Joseph Burris
RBS: In general, we should include the patient-centric Medicare requirements for each level of care in our diagrams, since these govern most payors’ (and doctors’) behavior most of the time. Hospice and Palliative Care, for example, require <6months prognosis for the patient to qualify –let’s add that to the pink slide.burris: added under bullet point 1
Joseph Burris
RBS: re home health. Pt has to be ‘homebound’ for home care- may as well use that term.burris: added as bullet point 1
AAPM&R -- Management of Stroke RehabilitationAcute Hospitalization
Physiatry/rehabilitation physician consultation during acute hospitalization for patients with stroke rehabilitation needs, evaluation and management planning:o NIHSS review
o Stroke recurrence risk factorso Secondary stroke prophylaxiso Medical comorbidities and effects on post acute care needso DVT prophylaxiso Cognition/communicationo Dysphagiao Nutrition o Mobility/self careo Bowel/bladder functiono Skin integrity o Caregiver availabilityo Patient/caregiver educationo Depression/mental health screeno Spasticityo Durable medical equipment/orthotic needs
Recommendation regarding transition to appropriate level of post acute care and follow up with physiatry/rehabilitation physician for future stroke rehabilitation needs
Transition to appropriate level of post acute care
Burris, Joseph E.
nguyen: Also, regarding discharge from acute inpatient rehabilitation, I think we need to make it clear that discharge is dependent on patient meeting functional goals AND that immediate medical needs have been resolved with plan for follow up. I bring this up because it seems at times that I have a medical issue that requires extra days despite the patient meeting impatient goals, and I get push-back from payers about it.
Burris, Joseph E.
nguyen: Will need to operationalized so that it is less wordy and more algorithmic in action – perhaps a flowchart to operationalize, then a click off or checklist
Burris, Joseph E.
nguyen: Need nutritional/dietary support for acute and post-acute institutional based for optimizing nutrition and caloric needs
Burris, Joseph E.
put in as nutrition assessment
Burris, Joseph E.
harvey: But additional findings on neurological examination not well measured in NIH might be included such as fine motor hand, manual testing (motricity index?), sitting balance and standing balance.
Burris, Joseph E.
harvey:
Burris, Joseph E.
We might want to discuss which depression screens might be appropriate.
Burris, Joseph E.
harvey: At my center communication may be assessed, but cognition is usually not assessed in detail. My residents will often to a mini-mental status, but we might want to suggest screening options for this.
Burris, Joseph E.
harvey: “Follow up with physiatry or physician with expertise in neurological rehabilitation” might be better wording. This should be used consistently throughout the document.
Burris, Joseph E.
harvey: In acute care, should “ongoing medical treatments” be added? For example, IV antibiotics, Dialysis, etc.
Burris, Joseph E.
added as a bullet point
Burris, Joseph E.
Just recommend adding to the RED section another bullet: “Patient, family and/or caregiver education and training in patient care needs” This should have the blue and green star too. If you all agree of course. I just worry there is no more room on the slide!
Burris, Joseph E.
education and training comment added to family/caregiver status, and slide 2 reflects changes for post acute levels of care
Burris, Joseph E.
nguyen: Will need to operationalized so that it is less wordy and more algorithmic in action – perhaps a flowchart to operationalize, then a click off or checklist
Burris, Joseph E.
agree, this document needs to be turned in to a flow diagram by someone with these skills-- will not be me :)
Burris, Joseph E.
algorithm embedded from last bullet point slide 1 to top bulled points for each level of post acute care in slide 2--hours of therapy for IRF and SNF, medical instability for LTAC
Burris, Joseph E.
nguyen: Acute: Include in the durable medical equipment needs should be orthosis evaluation for function and to minimize decline.
Burris, Joseph E.
this is included specifically in the DME bullet point
Joseph Burris
this is included specifically in the DME bullet point
Joseph Burris
RBS: Was the reference for the NIHSS prognosis levels the TOAST trial? If so, we may want to shift the category boundaries to the numbers they used - good recovery <7; variable recovery 7-15; likelihood of severe disability (sounds less bleak than ‘poor’); 16 or greater. These were 3 month recovery estimates, which makes them particularly applicable to the inpatient consult rehabilitation physician helping to direct the patient to the next level of care. Trial abstract is below for your review.burris: changed to reflect TOAST criteria if task force agrees
Needs to be considered by Physiatry/Rehabilitation Physician-Community discharge-Cognition/communication-Bowel/bladder management-Skin integrity-Mobility/self care-Medication management-Dysphagia/nutrition-Pain management-Spasticity management-Adjustment/mood disorders-DME, orthotic/assistive devices-Funding for care needs-Communication with other treating physicians
Skilled Nursing FacilitySkilled nursing and/or therapyPT,OT, SLP,TR, nursing, case management1-3 hrs of therapy 5 days/wkPM&R/rehabilitation physician for stroke rehab needs
Long Term Nursing FacilityCaregivers unable to meet patient’s needs In communityCustodial careFormal or restorative therapy as indicated
Long Term Acute CareMedical needs paramount3 day ICU stay at Acute hospital required PM&R/rehabilitation physician for stroke rehab needs
Inpatient Rehabilitation FacilityRehabilitation needs paramount - 3hrs/day 5 days/wk PT/OT/SLPInterdisciplinary team with expertise in stroke rehab
-PT,OT,SLP,TR, psychology, case management, nursingPM&R/rehabilitation physician visits 3-7x/wk
Needs to be considered by PM&R/rehabilitation physician--Cognition/communication-Bowel/bladder management-Skin integrity-Mobility/Self Care-Stroke rehab medication management-Dysphagia/nutrition-Pain management-Spasticity management-Adjustment and mood disorders-DME, orthotic/assistive devices-Funding for care needs-Communication with other treating physicians
Home HealthPatient is homebound, unable to travel to outpatient site.
PT, OT, SLP, HHA as needed 1-3X/wk. Skilled nursing required.
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