1. Stroke Reference Group Recommendations for Stroke Rehabilitation Presentation to the Rehab/CCC Expert Panel March 24,2011

2. Presentation Overview Proposed Evidence Based Best Practice Standards/Metrics Considerations Phase 1 Action Items Discussion

3. “Time is Function” Brain is “primed” to “recover” early post- stroke Delays in starting rehab are detrimental to recovery (Biernaskie et al., 2004). Day 5 admission = marked improvement Day 14 admission = moderate improvement Day 30 admission = no improvement vs. controls

4. Emergency Care Best Practice Standard: Emergency Department Evaluation and Management of Patients with TIA and Ischemic Stroke Acute Thrombolytic Therapy Acute Stroke Paramedic Prompt Card Protocol Minimize LOS Proposed Metrics: LOS For all pts admitted to stroke unit CT Scan within 24 hours of admission

5. Acute Care and Rehabilitation in the Acute Phase Standard: Patients admitted to hospital because of an acute stroke or transient ischemic attack should be treated on an interprofessional stroke unit [Evidence Level A]. Alpha FIM completed on Day 3 Discharge planning Mobilization within 24 hours of admission Prevention and management of Complications Following Acute Stroke Metrics: % admitted to stroke unit Onset to rehab: Ischemic Strokes- Day 5 Hemorrhagic strokes-Day 7 Alpha FIM completed Day 3 % of pts with ALC days All cause readmission rates % of pts with Alpha FIM categories who were d/c to planned rehab destination % d/c to inpatient rehab

6. Inpatient Rehabilitation Standard: Stroke Rehabilitation Unit Minimum of 3 hours of direct individualized therapy per day 7 day/week service 7 day/week admission process Rehabilitation ALC has priority access to LTC Metrics: Provincial workload definition of direct minutes of therapy per day( therapist vs assistant) Discharge destination ALC LOS ALC rates per X patients All cause readmission rates FIM efficiency by RPG NB: For Every 13 patients treated in a stroke rehab unit, 1 patient is saved from death or dependence

7. Ambulatory Rehabilitation/Community Care Best Practice Standard: Ambulatory rehab model (CCAC, community based, hospital based) Decrease admission of mild strokes through increased access to early outpatient rehab for those with high early FIM Access to enhanced attendant care/supports in early discharge phase for ALC pts Outpt or enhanced CCAC therapy visits: 2-3 visits/week for 12 weeks Metrics: CCAC referral date Time to first CCAC visit FIM Efficiency Readmission rate

8. Therapy is Cheap; LOS is Not Outpatient therapy improves short-term functional outcomes It is relatively inexpensive (1 PT/1 OT/0.5 SLP/0.5 SW = cost of 1 inpatient rehab bed) Reduces re-hospitalization and allows earlier discharge home Estimated savings is $2 for every $1 spent on outpatient therapies Only 3% of stroke rehab referrals from acute care were sent to day hospital / ambulatory care* *E-Stroke data 2009/2010

9. Is it possible/ Current initiatives? High variability seen across the province as far as onset days to rehab- a number of centres are doing quite well and even some freestanding centers e.g. St Johns Rehab 7 day admission & service Toronto Central LHIN clinical efficiency task group endorsed- detailed work to look at both streamlining Acute and Rehab care Pilot studies of enhanced outpatients have shown expected benefits ( Southwest and South east Ontario)

10. What is the Critical Mass?

11. Action Items to Accelerate Best Practices and Impact ALC Early Access: Mobilization within 24 hours of admission Alpha FIM  completed on Day 3 Alpha FIM  score > 80 = outpt rehabilitation Alpha FIM  score 40-80= inpatient rehabilitation Alpha FIM  score 40-60= ? Inpatient rehabilitation Alpha FIM  score <40= options for restorative/ongoing assessment Onset to Rehab: Ischemic strokes= Day 5 Hemorrhagic strokes= Day 7 Rehabilitation has same priority level as acute care for access to LTC

12. Action Items to Accelerate Best Practices and Impact ALC Intensification: 7 day a week admission process 7 day a week service Minimum 3 hours direct therapy per day Appropriate Settings: Acute and Rehabilitation Stroke Units Ambulatory and Community Rehabilitation Performance Management/Benchmarking: Establish accountabilities based on targets/metrics Support inclusion of Alpha FIM  in CIHI DAD Define workload measurement system provincially Establish Ambulatory care database

13. Discussion

14. What are the Cost Savings?

15. Projected Acute Care Savings from Earlier Admission to Inpatient Rehab # stroke patients discharged to rehab FY 09/10 Proposed stroke severity volumes to rehab¹ Volume based on stroke severity Onset to rehab admission days by stroke severity¹ Cost per diem $848 2 Targets to reduce onset days to rehab admission Total acute days saved Total acute care savings from earlier rehab admission 599 Mild 11% (↓ 42 pts) 6614$783,5527462$391,776 Moderate 60% 35919$5,784,208103,231$2,739,888 Severe 29% (↑ 42 pts) 174 26 $3,836,352 18 1,392$1,180,416 599$10,404,112$4,312,080 ³ ¹Based on E Stroke 08/09 – 22% severe, 18% mild (redirect 7%/1160) ²Conservative direct per diem. Savings may be greater in teaching hospitals where per diem rate is higher. Estimate provided by TC LHIN based on Ontario Case Costing Initiative (OCCI). ³Additional savings may be realised when LTLD clients included.

16. Changing Mix and Volume of Rehab Admissions Summary Costs Reallocation (90% occupancy) Savings from redirecting 42 mild stroke patients to outpatient : Saving use of 4 beds or $846,581 Cost savings from redirecting 66% (146) severe patients to intense rehab from LTLD: * range of 3 per diem estimates for LTLD Close 37 LTLD beds @ $291 (low) $3,929,955* Close 37 LTLD beds @ $364 (mean) $4,921,222* Close 37 LTLD beds @ $511.21 (high) $6,903,891* Subtotal Cost Savings:$4,776,536$5,767,803$7,750,472 Investment Required in Rehab Beds: Change severity mix and increase volume Require 23 new stroke rehab beds or $4,867,841 Investment Required in Outpatient Rehab: Cost for 2 hours outpatient therapy, 3x/wk @ 8 wks =$4800 (24 visits) for 42 new patients $191,520 Subtotal Rehab Investment: Cost for changing the rehab severity mix & outpatient rehab for mild stroke patients $5,059,361 Total Savings Realised Reallocation of resources from LTLD to HTSD Including the cost of additional outpatient resources for 42 mild strokes. Additional system saving realised if only 10% redirected home post rehab instead of LTC for one year $547,500 Low cost estimate of LTLD $4,776,536 -$5,059,361 -$282,825 Mean cost estimate of LTLD $5,767,803 - $5,059,361 $708,442 High cost estimate of LTLD $7,750,472 - $5,059,361 $2,691,111

17. Considerations Stroke units create a critical mass to develop specialization and skill competency in best practices Capacity to implement, integrate and sustain Alpha FIM into acute care Alpha FIM become part of CIHI DAD Availability of services and resources to support early transfer to rehab Outpatient therapy improves short-term functional outcomes Rehabilitation has the same prioritization level as acute care for access to LTC Alignment of funding to incent timely and appropriate pt access based on best practices