Final Final ReportReportFinal Final

ReportReportThe Stroke The Stroke Rehabilitation Pilot Rehabilitation Pilot

Project of SEOProject of SEOThis project was funded by the This project was funded by the

Ontario Ministry of Health, Long Ontario Ministry of Health, Long Term CareTerm Care

Cally Martin BScPT, MSc (Rehab)Cally Martin BScPT, MSc (Rehab)

John Paterson BEd, MSc (Rehab)John Paterson BEd, MSc (Rehab)

Patient and FamilyPatient and FamilyContinuum of careContinuum of care

The Ontario Stroke StrategyThe Ontario Stroke Strategy

Stroke recognition

Prevention

Pre-hospital

Emergency Acute

REHAB

Community

Transition

VISIONVISIONTo ensure that all Ontarians have access to To ensure that all Ontarians have access to the best possible quality stroke care, from the best possible quality stroke care, from prevention, through treatment and prevention, through treatment and rehabilitation, to community re-integration.rehabilitation, to community re-integration.

NORTHU

MBERLA

ND

Southeastern Ontario Region

Population 565,50012,500 miles2

20,000 km2

H

H

HH

H

HHH

H

H

H

The Discharge Link Project (DLP)The Discharge Link Project (DLP)

GoalTo investigate best practice related to stroke client transition from inpatient rehabilitation to the community by:

enhancing therapy augmenting provider

communication

The DLP ProcessThe 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

The DLP ProcessThe 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

The DLP ProcessThe DLP ProcessEvaluation 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

DLP Distribution of Participants DLP Distribution of Participants

Total of 61 (24 U + 37 E)

Groups were well matchedCommunity Care Access Centre

Usual care

group

Enhanced

therapy group

Totals

Hastings and Prince Edward (HPE)

6 12 18

Kingston, Frontenac, Lennox & Addington Counties (KFL&A)

8 13 21

Lanark, Leeds and Grenville (LLG)

10 12 22

Totals 24 37 61

DLP Severity of StrokeDLP Severity of Stroke FRG = Functionally Related Group (at

Admission) Based on ratio of motor and cognitive sub-

scores on the FIM

0123456789

participants

1 2 3 4 5 6 7 8 9

FRG Category

NormalEnhanced

Stroke FRGs Organized into Upper, Middle & Lower Bands

Stroke FRGs Organized into Upper, Middle & Lower Bands

Motor

Motor

Motor

Motor

Motor

Cognitive

CognitiveAge

FRGMedianLOS

>48

13-48

>62

49-62

38-48

13-37

16-74

>74

>30

5-30

74-91

63-73

56-62

49-55

18-35

5-17

9

8

7

6

5

4

3

2

1

9.0

13.0

15.0

18.0

21.0

27.0

32.0

28.0

36.0

Upper Band

Middle Band

Lower Band

Functional Task Benchmarks for Stroke Rehabilitation. Margaret G. Stineman, MD, Roger C. Fiedler, PhD,Carl V. Granger, MD, Greg Maislin, MS, MA. Arch Phys Med Rehabil Vol. 79, May 1998 Pg. 499

DLP: LOS and Wait Times DLP: LOS and Wait Times

Total time post onset U=106.5U=106.5 E=96.7E=96.7

23.0

7.635.3

28.1

53.8

56.6Usual Care

Enhanced

Days

Acute LOS

Rehab LOS

Wait time forCCAC

DLP: Community Provider

Service (First 2 months, incl. 12 Link

Meetings)

DLP: Community Provider

Service (First 2 months, incl. 12 Link

Meetings)

16.1

22.4

3.5

11.3

0 5 10 15 20 25

Usual CareEnhanced

DLP: Functional Recovery DLP: Functional Recovery

70

80

90

100

110

Admiss

ion t

o reh

ab

Discha

rge f

rom Reh

ab

3 mon

th fo

llow up

6 mon

th fo

llow up

12 m

onth fo

llow up

Mea

n FIM

sco

re

Usual CareEnhancedintervention

DLP: Functional Recoverybetween Discharge and

3 mths

DLP: Functional Recoverybetween Discharge and

3 mths

76.3

107.5105.5

74.4

99.4

108.3107.7

109.2107.9107.5

70

80

90

100

110

Admissionto rehab

Dischargefrom

Rehab

3 monthfollow up

6 monthfollow up

12 monthfollow up

Mean

FIM

score N

E

DLP: Change in Recovery DLP: Change in Recovery

25

7.311.5 11

31.3

-2.1

0.2

-2-5

0

5

10

15

20

25

30

35

ADM - DIS DIS - 3mths

DIS - 6mths

DIS - 12mths

Mean c

hange in

FIM

sco

re

Usual CareEnhanced

Regression AnalysisRegression 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 p<0.05

# evidence of contribution to the model

DLP: Hospital ReadmissionsDLP: Hospital Readmissions

U(24)U(24) E (37)E (37)

Re-hospitalizations 11(46%) 9(24%)

Total bed-days 133 73Ave days per stay 8.3

6.1

DLP: Reasons for ReadmissionsDLP: Reasons for Readmissions

Usual Care Group

Fall, multiple fracturesFall, Pelvic fracture

TIA, SeizurePneumoniaInfectionHeart Condition

Enhanced Care Group

Knee replacementHip replacementBypass Surgery

TIA, SeizurePneumoniaInfectionHeart Condition

DLP: Hospital Readmissions - CostsDLP: Hospital Readmissions - Costs

$87,514

$3646

$0

$20,000

$40,000

$60,000

$80,000

$100,000

Overall Cost Cost perperson

Cost of Re-Hospitalizations

Enhanced (37)

Usual Care (24)

DLP: Cost ComparisonsDLP: Cost Comparisons

1,298

2,146

3,4443,646

509

4,155

$0$500

$1,000$1,500$2,000$2,500$3,000$3,500$4,000$4,500

ave. re-admission

cost

ave. cost ofcommunity

therapy

net cost

cost

per pers

on

Usual CareEnhanced

““A cycle of discontinuity”A cycle of discontinuity”

“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!”

Key informant interviews:Voices of Providers….Key informant interviews:Voices of Providers….

Key informant interviews:Voices of clients….Key informant interviews:Voices of clients….

“I am totally overwhelmed”

““Horrific”Horrific”““Hell on earth”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?”

DLP RecommendationsDLP Recommendations

1. Provide enhanced & timely professional therapy for stroke clients

2. Consider priority setting for those recovering from new stroke

3. Increase system responsiveness and flexibility

4. Establish a formal process for coordination of care

5. Promote models of care that promote client recovery

DLP Recommendations, p2DLP Recommendations, p2

6. Investigate strategies to recruit and retain professional services and promote stable provider workforce

7. Provide stroke rehab education to CCAC, professional staff and PSWs

8. Explore role of OT, PT communication assistants

9. Support caregivers

10.Regional planning

Thank you!Thank you!

The Ontario Ministry of Health, Long-Term Care for funding the project

The Rehab subcommitteeCCACs and Hospitals of SEOCare providersClients, Caregivers/Family