Final Report

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Final Report

• The Stroke Rehabilitation Pilot Project of SEO
• This project was funded by the
• Ontario Ministry of Health, Long Term Care
• Cally Martin BScPT, MSc (Rehab)
• John Paterson BEd, MSc (Rehab)

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The Ontario Stroke Strategy
Patient and Family Continuum of care

Emergency
Acute
Pre-hospital
Transition
Prevention
REHAB
Community
Stroke recognition
VISION To ensure that all Ontarians have access
to the best possible quality stroke care, from
prevention, through treatment and rehabilitation,
to community re-integration.
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Southeastern Ontario Region
H
Population 565,500 12,500 miles2 20,000 km2
NORTHUMBERLAND
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The Discharge Link Project (DLP)

• Goal
• To investigate best practice related to stroke
  client transition from inpatient rehabilitation
  to the community by
• enhancing therapy
• augmenting provider communication

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The DLP Process

• Participants included
• Adults with new stroke
• Recently discharged from inpatient rehab
• Require home care
• Going home or to residential setting
• Excluded
• Those going to LTC

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The DLP Process

• The Enhanced Therapy (first 2 mths)
• Pre-Discharge Link Meeting (OT to OT)
• Post-Discharge OT PSW meeting
• Month 1
• up to 2 extra visits/wk OT, PT and/or SLP
• 5 hours extra PSW/wk
• Month 2
• up to 1 extra visit/wk OT, PT and/or SLP
• Allocation to group ability of CCAC to provide
  enhanced service

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The DLP Process

• Evaluation
• Function
• FIM (CIHI-NRS) at Rehab Admission and Discharge,
  3, 6 12 mos after discharge
• RNL and Health Status at 3mos
• Client satisfaction survey
• Key Informant Interviews focus groups
• CCAC workload
• Hospital readmissions
• Qualitative and quantitative analysis

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DLP Distribution of Participants

• Total of 61 (24 U 37 E)
• Groups were well matched

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DLP Severity of Stroke

• FRG Functionally Related Group (at
  Admission)
• Based on ratio of motor and cognitive
  sub-scores on the FIM

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Stroke FRGs Organized into Upper, Middle Lower
Bands
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DLP LOS and Wait Times

• Total time post onset U106.5 E96.7

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DLP Community Provider Service (First 2
months, incl. 12 Link Meetings)
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DLP Functional Recovery
intervention
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DLP Functional Recovery between Discharge and
3 mths
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DLP Change in Recovery
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Regression Analysis

• The most significant predictors of the improved
  change in function were
• 1. FIM score at Discharge p
  0.004
• 2. Rehab Care Professional Visits p 0.169
• significant at plt0.05
• evidence of contribution to the model

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DLP Hospital Readmissions

• U(24) E (37)
• Re-hospitalizations 11(46) 9(24)
• Total bed-days 133 73
• Ave days per stay 8.3 6.1

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DLP Reasons for Readmissions

• Usual Care Group
• Fall, multiple fractures
• Fall, Pelvic fracture
• TIA, Seizure
• Pneumonia
• Infection
• Heart Condition

• Enhanced Care Group
• Knee replacement
• Hip replacement
• Bypass Surgery
• TIA, Seizure
• Pneumonia
• Infection
• Heart Condition

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DLP Hospital Readmissions - Costs
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DLP Cost Comparisons
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Key informant interviewsVoices of Providers.
You get so used to working within a system that
you you forget that there might be something
better out there... I finally get to do real
OT!
A cycle of discontinuity
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DLP Other Findings

• U E
• Reintegration to Normal Living
• (3 mths, max 22) 15.7 14.5
• (6 mths, max 22) 16.5 15.4
• How would you describe your own health?
• poor 7 0
• fair 11 21
• good 50 38
• very good 32 41
• excellent 0 0

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DLP Client Satisfaction (CCAC Survey Scores)
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DLP Key Informant Interview Process 14
people clients, caregivers and providers 8
focus groups of 120 people
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Key informant interviewsVoices of clients.

• I am totally overwhelmed
• Horrific
• Hell on earth
• It was hard. It was tough
• if spouses become therapists it really
• degrades and demises the personal
  relationship.
• What do you do?

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DLP Interview Summary

• Chronic shortage of therapists
• Timely professional service has
• significant impact on recovery
• Travel costs for remote participants
• Flexibility needed in community therapy
• System barriers complicate the integration of
  care
• Need for stroke education in the community
• Role of PSWs in community
• Caregivers are overwhelmed

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DLP Summary of Results

• Function Access
• - Significantly improved change in function
  with enhanced professional therapy in first 2
  months
• - Community service at transition point means
  faster functional recovery
• Satisfaction Patient, Caregiver Provider
• - time for collaboration important
• - caregivers are overwhelmed
• - System barriers frustrate providers
• Utilization
• - enhanced therapy half the readmissions to
  hospital
• - models of community care differ widely

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DLP Recommendations

• Provide enhanced timely professional therapy
  for stroke clients
• Consider priority setting for those recovering
  from new stroke
• Increase system responsiveness and flexibility
• Establish a formal process for coordination
  of care
• Promote models of care that promote client
  recovery

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DLP Recommendations, p2

• Investigate strategies to recruit and retain
  professional services and promote stable provider
  workforce
• Provide stroke rehab education to CCAC,
  professional staff and PSWs
• Explore role of OT, PT communication assistants
• Support caregivers
• Regional planning

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DLP Sustainability

• Cost Effectiveness
• Enhanced and timely therapy increases function
  and may decrease utilization
• Client selection important
• Regional planning mechanisms to maximize service
• Resourced transition planning has long term
  benefits

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DLP Transferability

• Results are transferable to people who
• live anywhere, regardless of where
• have a new disability and
• cant access service
• have the potential
• to recover
• are in LTC?

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Thank you!

• The Ontario Ministry of
• Health, Long-Term Care
• for funding the project
• The Rehab subcommittee
• CCACs and Hospitals of SEO
• Care providers
• Clients, Caregivers/Family