S TROKE R EHABILITATION R EBUILDING A LIFE Marla Rose, Speech Language Pathologist Trinity Hospital

O BJECTIVES Discuss the multiple levels of rehabilitation Therapeutic services provided from acute care to home. Therapeutic rationale for intervention and for discharge planning

W HO 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.

T RINITY H OSPITAL 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

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

ROAD TO RECOVERY

R ECOVERY 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

M ULTIPLE L EVELS OF R EHABILITATION Home – Independent Home + Outpatient tx Home + Home Care Skilled Nursing Facility Inpatient Rehab Acute Care

F ACTORS 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

R EHABILITATION TEAM Patient and family Physicians Physical Therapist Occupational Therapist Speech-language Pathologist Nurses Dietician Social Worker Orthotist Mental Health Insurance Company Community Resources

A CUTE C ARE A CUTE 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

A CUTE C ARE A CUTE 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

A CUTE C ARE 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

A CUTE D ISCHARGE 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; 3 rd party payer.

R EHABILITATION T HEORY 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

R EHABILITATION T HEORY 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

R EHABILITATION 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.

M EDICARE ’ S E XPECTATION 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.

I NPATIENT REHAB Trinity Hospital – St. Joseph’s Campus

I NPATIENT REHAB W HAT YOU N EED 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

A DMIT S EVERITY : H OW 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

I NPATIENT REHAB HOW IS IT DIFFERENT Therapy intensity Mandatory participation Therapy staff Social Worker Medical director – visits patients daily Nursing staff and the scope of their responsibilities

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

N URSING S TAFF They’re not ONLY nurses They’re NURSE THERAPISTS

I NPATIENT R EHAB N URSING S TAFF 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.

I NPATIENT R EHAB O UTCOMES # of stroke patients Average Age ALOS (days) D/C Home 80% 74% D/C SNF 16% 17% Ave FIM gain points (target: 28 points)

P HYSICAL T HERAPY Exercises to address the sensory-motor physiology Apply the physiological gains to functional ADLs

O CCUPATIONAL T HERAPY Exercises to address the sensory-motor physiology Apply the physiological gains to functional ADLs

S PEECH -L ANGUAGE P ATHOLOGY Exercises to address the sensory-motor physiology of swallowing Apply the physiological gains to functional swallow

S PEECH -L ANGUAGE P ATHOLOGY Exercises to address neurological processing and/or physiology for communication skills Apply gains to functional communication interactions

S KILLED N URSING F ACILITY 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

S KILLED N URSING F ACILITY 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

H OME WITH H OME C ARE Scenario # 1 Patient discharged from inpatient rehab with recommendations to continue therapy. Scenario #2 Patient discharged from acute care with recommendations for therapy.

H OME WITH H OME C ARE 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

H OME WITH O UTPATIENT T HERAPY 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.

H OME WITH O UTPATIENT T HERAPY 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

T HROUGH ALL LEVELS OF REHABILITATION Patient goals Medicare/3 rd party payer expectations Neuroplasticity theory Target actual functional use BEFORE compensatory training