Vertical Strategic Planning for Stroke Care

in PM&RRandie Black-Schaffer, M.D.

Department of Physical Medicine and Rehabilitation,

Harvard Medical School, Boston MA

I have no financial relationship with a

commercial entity producing healthcare-related

products or services.

Vertical Strategic Planning at the AAPMR

• 2011 ‘Positioning the Specialty’ summit– Drill down on specific areas of care vs. addressing

in aggregate– Move away from ‘horizontal’ planning to a

‘vertical’ approach

• 2012-13 clinical conditions identified and prioritized by Board of Governors

• 2013 Stroke and Spine pilot groups meet • 2014 VP Stroke and Spine Taskforces formed

Vertical Planning for Stroke Rehabilitation AAPMR taskforce

• Randie Black-Schaffer, MD (Chair) Spaulding Rehabilitation Hospital/Harvard Medical School, Boston

• Joseph Burris, MD (Chair, Pathways subcommittee) University of Missouri, Columbia

• Steven Flanagan, MD NYU Langone Medical Center, New York• Darryl Kaelin, MD Frazier Rehabilitation Institute/University of Louisville, Kentucky

• Joel Stein, MD Columbia University Medical Center/NY-Presbyterian Hospital/Weill

Cornell Medical College, New York City

Vertical Planning Concept

Stroke SpinePractice

LegislationAdvocacyEducation Communications

Vertical Planning for Stroke

• Position the specialty to adopt a pivotal role in providing post-acute care for stroke patients

• Develop initiatives to improve post-acute stroke care and enhance the role of PM&R in stroke care

• Harness the resources of AAPMR to help accomplish these goals

VP -Practice & Advocacy

1. Develop an AAPMR consensus statement on optimal post-acute care pathways for stroke patients - Stroke VP Pathways Task Force

2. Develop innovative practice models for physiatrists caring for stroke patients

- Practice Preparedness Committee

3. Work toward inclusion in stroke national care guidelines of standards for care throughout the initial episode of care and beyond. – Clinical Practice Guidelines Committee

VP - Education

1. Create knowledge/practice/regulatory tools to help physiatrists care for patients in all post-acute settings

– CME – CME, Program Planning Committees– SNF Medical Director Certificate Program – Practice

Preparedness Committee

3. Create educational tools for external stakeholders - Public and Professional Awareness Committee (PPAC)

2. Promote residency training in all post-acute settings - AAP, ACGME

VP - Communication

1. Build awareness within PM&R of recommended patient pathways and practice options – AAPMR website, publications, CME

2. Build awareness across related specialty organizations, e.g. ASA, AAN, of these patient pathways for post-acute stroke care – member relationships, PPAC

3. Educate the public about the post-acute care continuum and physiatry’s role in assuring optimal care for stroke patients across the continuum - Communication resources of the Academy

1. Stroke Rehabilitation Consultation in the Neuro Intensive Care Unit

2. Skilled nursing facility stroke rehabilitation

3. Long-term outpatient management

Physiatry in the Neuro ICU– Early Mobilization– Contracture avoidance– Eval and management of Critical Illness

myopathy/polyneuropathy– Use and timing of neurostimulants– Sleep/Wake cycle management– Neurogenic bowel/bladder– Spasticity management– Assessment of rehabilitation candidacy

Physiatry in SNF Rehab• 6-7% of pts in SNF rehab are there for stroke

(Dobson/Davanzo 2014)

• 5% have a Physiatry visit (Kramer 1997)

• CMS SNF requirements: – Skilled therapy 5x/wk – no time requirement– MD visit minimum q 30 days, and as ‘medically

necessary’– RN present in facility 8hrs/day

Value added by PM&R for stroke patients in SNF Rehab

Spasticity/hypertonicity management Pain management Orthotics and assistive devices Education and training for patient and caregivers Consultant to rehabilitation therapists Adjustment and mood disorders Bowel/bladder Skin integrity Consultant to nursing staff Assistance with goal of community discharge

Challenges for PM&R in SNF Rehab

• Nursing, therapy, MD staffing• Therapy equipment• Team process

– Assessment – MDS at Day 5, Day 14, Day 30, Day 60, and Day 90 to determine RUG group

– Care plan, Discharge plan

• Ancillary services often less available• Consultant vs. Attending vs. Medical Director

Physiatry in Longterm Outpatient Stroke Management

• 4.6 million community stroke survivors in US.

Brønnum-Hansen et al. Stroke. 2001;32:2131-2136

Patients 65 or older at time of stroke

Observed survival after a first-ever ischemic stroke (heavy line) or TIA (thin line) and expected survival (dashed line) based on the age- and sex-matched Italian population.

Carmine Marini et al. Stroke. 1999;30:2320-2325

Copyright © American Heart Association, Inc. All rights reserved.

Longterm OPD PM&R Management of Stroke Sequelae

• Pro-active management of:– Spasticity– Pain– Function – Orthotics/Assistive devices/DME – Rehabilitation therapies– MSK complications

• Wellness – exercise, weight, diet

Physiatry Challenges in the OPD

• Many issues – too little time!• Lack of clear standards of care for long term

management of stroke sequelae• Opportunity for Telehealth visits?

Thank you! rblackschaffer@partners.org

Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston MA