Vertical Strategic Planning for Stroke Care in PM&R Randie 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. 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 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 StrokeSpine Practice Legislation Advocacy Education 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: 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: 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! Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston MA