Differences in Daily Activity Performance Between Inpatient Rehabilitation Facility and Home Among Stroke Survivors.

In the United States, the incidence rate of new or recurrent stroke is approximately 795 000 per year, and stroke prevalence for individuals over the age of 20 years is estimated at 6.5 million.1 Mortality rates in the first 30 days after stroke have decreased because of advances in emergency medicine and acute stroke care. In addition, there is strong evidence that organized postacute, inpatient stroke care delivered within the first 4 weeks by an interdisciplinary healthcare team results in an absolute reduction in the number of deaths.2,3 Despite these positive achievements, stroke continues to represent the leading cause of long-term disability in Americans: An estimated 50 million stroke survivors worldwide currently cope with significant physical, cognitive, and emotional deficits, and 25% to 74% of these survivors require some assistance or are fully dependent on caregivers for activities of daily living (ADLs).4,5 Notwithstanding the substantial progress in acute stroke care over the past 15 years, the focus of stroke medical advances and healthcare resources has been on acute and subacute recovery phases, which has resulted in substantial health disparities in later phases of stroke care. Additionally, healthcare providers (HCPs) are often unaware of not only patients’ potential for improvement during more chronic recovery phases but also common issues that stroke survivors and their caregivers experience. Furthermore, even with evidence that documents neuroplasticity potential regardless of age and time after stroke,6 the mean lifetime cost of ischemic stroke (which accounts for 87% of all strokes) in the United States is an estimated $140 000 (for inpatient, rehabilitation, and follow-up costs), with 70% of first-year stroke costs attributed to acute inpatient hospital care1; therefore, fewer financial resources appear to be dedicated to providing optimal care during the later phases of stroke recovery. Because there remains a …

Responsiveness of the activity measure for post-acute care (AM-PAC) from discharge from inpatient stroke rehabilitation to six month follow-up

Interventions are needed to support the long-term needs of stroke survivors when they transition from inpatient rehabilitation to home, where they face new home and community environmental barriers. To compare the efficacy of a novel, enhanced rehabilitation transition program with attentional control to improve community participation and activity of daily living (ADL) performance and to reduce environmental barriers in the home and community after stroke. This phase 2b, parallel randomized clinical trial assessed patients 50 years or older who had experienced an acute ischemic stroke or intracerebral hemorrhage, were independent in ADLs before stroke, and planned to be discharged home. Patients were assessed at an inpatient rehabilitation facility in St Louis, Missouri, and their homes from January 9, 2018, to December 20, 2023. Community Participation Transition after Stroke (COMPASS), including home modifications and strategy training. The primary outcome was community participation (Reintegration to Normal Living Index). Secondary outcomes were daily activity performance (Stroke Impact Scale ADL domain and the In-Home Occupational Performance Evaluation [I-HOPE] activity, performance, and satisfaction scores) and environmental barriers in the home (I-HOPE environmental barriers score). A total of 185 participants (mean [SD] age, 66.3 [9.0] years; 105 [56.8%] male) were randomized (85 to the COMPASS group and 100 to the control group). The COMPASS and control participants experienced similar improvements in community participation by 12 months, with no significant group (mean difference, 0.3; 95% CI, -4.6 to 5.2; P = .91) or group × time interaction (between-group differences in changes over time, 1.3; 95% CI, -7.1 to 9.6; P = .76) effects. Improvements in I-HOPE performance and satisfaction scores were greater for COMPASS participants than control participants at 12 months (between-group differences in changes for performance: 0.39; 95% CI, 0.01-0.77; P = .046; satisfaction: 0.52; 95% CI, 0.08-0.96; P = .02). The COMPASS participants had greater improvements for I-HOPE environmental barriers than the control participants (P = .003 for interaction), with the largest differences at 6 months (between-group differences in changes: -15.3; 95% CI -24.4 to -6.2). In this randomized clinical trial of stroke survivors, participants in both groups experienced improvements in community participation. COMPASS participants had greater improvements in self-rated performance and satisfaction with performing daily activities as well as a greater reduction in environmental barriers than control participants. COMPASS reduced environmental barriers and improved performance of daily activities for stroke survivors as they transitioned from inpatient rehabilitation to home. ClinicalTrials.gov Identifier: NCT03485820.

Health care reform legislation and Medicare plans for unified payment for postacute care highlight the need for research examining service delivery and outcomes. To compare functional outcomes in patients with stroke after postacute care in inpatient rehabilitation facilities (IRF) vs skilled nursing facilities (SNF). This cohort study included patients with stroke who were discharged from acute care hospitals to IRF or SNF from January 1, 2013, to November 30, 2014. Medicare claims were used to link to IRF and SNF assessments. Data analyses were conducted from January 17, 2017, through April 25, 2019. Inpatient rehabilitation received in IRFs vs SNFs. Changes in mobility and self-care measures during an IRF or SNF stay were compared using multivariate analyses, inverse probability weighting with propensity score, and instrumental variable analyses. Mortality between 30 and 365 days after discharge was included as a control outcome as an indicator for unmeasured confounders. Among 99 185 patients who experienced a stroke between January 1, 2013, and November 30, 2014, 66 082 patients (66.6%) were admitted to IRFs and 33 103 patients (33.4%) were admitted to SNFs. A higher proportion of women were admitted to SNFs (21 466 [64.8%] women) than IRFs (36 462 [55.2%] women) (P < .001). Compared with patients admitted to IRFs, patients admitted to SNFs were older (mean [SD] age, 79.4 [7.6] years vs 83.3 [7.8] years; P < .001) and had longer hospital length of stay (mean [SD], 4.6 [3.0] days vs 5.9 [4.2] days; P < .001) than those admitted to IRFs. In unadjusted analyses, patients with stroke admitted to IRF compared with those admitted to SNF had higher mean scores for mobility on admission (44.2 [95% CI, 44.1-44.3] points vs 40.8 [95% CI, 40.7-40.9] points) and at discharge (55.8 [95% CI, 55.7-55.9] points vs 44.4 [95% CI, 44.3-44.5] points), and for self-care on admission (45.0 [95% CI, 44.9-45.1] points vs 41.8 [95% CI, 41.7-41.9] points) and at discharge (58.6 [95% CI, 58.5-58.7] points vs 45.1 [95% CI, 45.0-45.2] points). Additionally, patients in IRF compared with those in SNF had larger improvements for mobility score (11.6 [95% CI, 11.5-11.7] points vs 3.5 [95% CI, 3.4-3.6] points) and for self-care score (13.6 [95% CI, 13.5-13.7] points vs 3.2 [95% CI, 3.1-3.3] points). Multivariable, propensity score, and instrumental variable analyses showed a similar magnitude of better improvements in patients admitted to IRF vs those admitted to SNF. The differences between SNF and IRF in odds of 30- to 365-day mortality (unadjusted odds ratio, 0.48 [95% CI, 0.46-0.49]) were reduced but not eliminated in multivariable analysis (adjusted odds ratio, 0.72 [95% CI, 0.69-0.74]) and propensity score analysis (adjusted odds ratio, 0.75 [95% CI, 0.72-0.77]). These differences were no longer statistically significant in the instrumental variable analyses. In this cohort study of a large national sample, inpatient rehabilitation in IRFs for patients with stroke was associated with substantially improved physical mobility and self-care function compared with rehabilitation in SNFs. This finding raises questions about the value of any policy that would reimburse IRFs or SNFs at the same standard rate for stroke.

A gap in care for stroke survivors exists at the point of transition from inpatient rehabilitation to home, when survivors encounter new environmental barriers because of the cognitive and sensorimotor sequelae of stroke. Resolving these barriers and improving independence in the community have the potential to significantly improve stroke survivors' long-term morbidity. To investigate the efficacy and safety of a novel enhanced rehabilitation transition program to reduce environmental barriers and improve daily activity performance and community participation among stroke survivors. This is a phase 2b, single-blind, parallel-group, randomized clinical trial. Participants will be randomized using a 1:1 allocation ratio, stratified by Functional Independence Measure and age, to either attentional control or the intervention. Community Participation Transition After Stroke (COMPASS) is a complex intervention that uses 2 complementary evidence-based interventions: home modifications and strategy training delivered in the home. Community participation after stroke, measured by the Reintegration to Normal Living Index, is the primary outcome. Secondary outcomes include quality of life after stroke, measured by the Stroke Impact Scale, and daily activity performance and magnitude of environmental barriers in the home, both measured by the In-Home Occupational Performance Evaluation. An intention-to-treat analysis will be used. A total of 180 participants, who are 50 years or older, were independent in activities of daily living prior to stroke, and are undergoing inpatient rehabilitation following stroke with a plan to be discharged home, will be included in the study. Stroke is a leading cause of serious long-term disability in the United States. The COMPASS study is ongoing. To date, 99 participants have been recruited and 77 randomized, with 37 in the treatment group and 40 in the control group. Resumption of previous activities immediately after discharge can improve immediate and long-term community participation. Results from this study will fill a critical gap in stroke rehabilitation evidence by providing important information about the long-term community participation and daily activity performance among stroke survivors as well as environmental barriers in their homes. ClinicalTrials.gov identifier: NCT03485820.

Introduction/Hypothesis: Caregiver training and education plays an important role throughout the post-stroke recovery continuum. The comfort level and competence of these caregivers in providing the support and assistance necessary is often the determining factor for a stroke survivor’s ability to return to their community dwelling. In this study, we hypothesized that a comprehensive, multidisciplinary caregiver education and training (Care Partner) program would improve functional outcomes and discharge to community outcomes of stroke patients at an acute inpatient rehabilitation facility (IRF). Methods: The Care Partner program was established as a comprehensive multidisciplinary training and education program for stroke patients and their caregivers at an IRF. Data was collected for patient’s discharge destination, case mix index (CMI), and functional improvements according to the FIM (Functional Independence Measure) and compared to facility, regional, and national benchmarks. Results: In 2016, 41 out of 252 total stroke patients participated in the Care Partner program. The participant discharge to community rate was 87%, which is higher than facility (67.8%), regional (60.4%), and national (64.6%) levels of stroke patient populations. Additionally, the FIM change per stay for participants was 33.04 as compared to facility (27.65), regional (24.73) and national (23.84). The participant FIM change per stay is significantly higher, which equates to a higher functional level upon discharge. The CMI for participants was 2.02 as compared to the facility (1.64), regional (1.63), and national (1.54), which denotes a much greater burden of care. However, even with a greater care burden, the participants in the PSHR Care Partner program had better quality outcomes when compared to the non-participants. Conclusion: The Care Partner program improves a stroke survivor’s ability to return to their community dwelling with greater functional independence when being discharged from an IRF.

Functional Trajectory of Childhood Stroke in the Inpatient Rehabilitation Setting

Characteristics of Acute Stroke Patients Readmitted to Inpatient Rehabilitation Facilities: A Cohort Study.

Background: Inpatient rehabilitation facilities (IRFs) are central to post-stroke recovery, yet large-scale analyses of the association of post-cute IRF care with major adverse cardiovascular events (MACE) among acute ischemic stroke (AIS) survivors are lacking. We evaluated the association between discharge to IRF, compared to home (with or without home health services) or skilled nursing facilities (SNFs), and the 1-year risk of MACE and other vascular outcomes. Methods: We identified adult AIS survivors (≥18 years) from statewide inpatient and emergency department databases of Florida, New York, Maryland, Washington, and Georgia (2016–2019). We fit multivariable Cox regression models to evaluate the association of IRF care with the 1-year risk of experiencing MACE (a composite of AIS, intracerebral hemorrhage [ICH], vascular death [VD], and acute myocardial infarction [AMI]), VD, and all-cause mortality. Fine-Gray models, with death as a competing risk, were used for 1-year recurrent AIS (r-AIS), ICH, and AMI. Adjusted hazard ratios (aHR), sub-distribution hazard ratios (aSHR), and 95% CIs are reported. Results: Among 316,499 AIS survivors (median age [IQR]: 71 [61–81] years; 49.1% female), 63.6% were discharged home, 16.0% to IRF, and 20.4% to SNF. Patients discharged home (53.5%) or to IRF (51.4%) were predominantly male (vs. SNF: 42.3%). Median age was lower for home (68 years) and IRF (70 years) than SNF (80 years). Medicare was most common among SNF discharges (86%), while private insurance was more frequent in home (22.9%) and IRF discharges (17.6%) than SNF (6.3%). At 1 year, 6.7% of AIS patients experienced MACE, and 6.6%, 0.3%, 0.9%, 0.5%, and 2.0% experienced r-AIS, ICH, AMI, VD, and mortality, respectively. IRF discharge was associated with a lower risk of MACE (aHR, 95% CI: 0.79, 0.75–0.82 vs. home; 0.76, 0.73–0.80 vs. SNF), r-AIS (aSHR, 95% CI: 0.78, 0.74–0.81 vs. home; 0.76, 95% CI 0.72–0.80 vs. SNF), AMI (aSHR, 95% CI: 0.84, 0.75–0.94 vs. home; 0.89, 0.78–1.01 vs. SNF), ICH (aSHR, 95% CI: 0.81, 0.66–0.99 vs. SNF), VD (aHR 95% CI: 0.83, 0.71–0.98 vs. SNF) and all-cause mortality (aHR 95% CI: 0.65, 0.60–0.70 vs. SNF). Conclusions: Post-acute IRF care represents a modifiable target to reduce adverse vascular events after AIS. However, only 16% of survivors receive IRF care, with marked age, sex, and insurance disparities. Expanding access to IRFs potentially offers an opportunity to improve population-level outcomes among AIS survivors.

The purpose of this systematic review was to examine quality care indicators for inpatient stroke rehabilitation, trends for length of stay (LOS), functional outcomes, and discharge destination. In order to examine the influence of the prospective payment system (PPS), which was instituted in 2002, particular attention was paid to the pre-PPS to post-PPS period. This is the first review of literature to examine the quality of stroke care provided in inpatient rehabilitation facilities in the United States. A search of Ovid Medline and Ovid Cumulative Index of Nursing and Allied Health databases was performed for articles published between 1990 and 2007. Search terms included treatment outcome, outcome assessment, activities of daily living, exercise, rehabilitation, cerebrovascular accident, LOS, and rehabilitation centers. Twelve articles met the criteria for review. A trend for shorter LOS was evident in the literature up until the time of implementation of PPS. An insufficient amount of literature was available to confirm whether this trend continued after the implantation of PPS. The most recent data indicated that average LOS in inpatient rehabilitation facilities for stroke was <20 days. Functional Independence Measure (FIM) discharge scores remained stable through the 1990s. After the implementation of PPS, discharge FIM scores may be decreasing, but revisions to the FIM tool may confound interpretation of post-PPS findings. Data for discharge to noninstitutional settings after stroke rehabilitation were inconclusive pre-PPS. There may be indications that discharges to institutional settings are increasing post-PPS. The impact of PPS on quality care indicators for inpatient stroke rehabilitation, trends for LOS, and trends for functional outcomes are insufficiently documented in the medical literature. Further research is needed to understand the influence of LOS on functional outcomes and discharge destination. More information is needed on post-PPS outcomes to substantiate the benefit of inpatient rehabilitation for individuals with stroke.

Functional outcomes after inpatient rehabilitation for trauma—improved but unable to return home

The prevalence and extent of cognitive-communication disorders and factors that have impact on outcomes are examined in the burn population within an inpatient rehabilitation facility. A retrospective data analysis was conducted on adults diagnosed with burn injury (n = 144). Descriptive statistics were used to identify the prevalence of cognitive-communication deficits on admission and discharge. The main outcomes were cognitive-communication ratings on discharge from inpatient rehabilitation as measured by the memory and problem-solving domains of the Functional Independence Measure (FIM) and composite score of the Functional Communication Measure (FCM). Medical, demographic and rehabilitation predictors of the main outcomes were assessed using regression analyses. On admission to inpatient rehabilitation, 79% of the total population presented with cognitive-communication impairments, and of them, 27% presented with persistent deficits on discharge. Admission FIM memory score, marital status, and age were significant predictors of discharge FIM memory score. Admission FIM problem-solving score, age, marital status, and prehospital living-with were significant predictors of discharge FIM problem-solving score. Admission FCM score and age were significant predictors of discharge FCM cognitive score. Persons with burn injuries are at risk for cognitive-communication impairments, which may persist after inpatient rehabilitation. FIM data obtained on admission can be used as a screening tool to identify these at-risk patients. Future work is needed to assess the efficacy of speech-language pathologist intervention for cognitive-communication deficits within the burn injury population.

The American Heart Association and American Stroke Association recommend early identification of level of rehabilitative care as a priority after stroke. To evaluate the utility of the Activity Measure for Post-Acute Care (AM-PAC) "6 Clicks" Daily Activity and Basic Mobility forms to determine the next level of rehabilitation after hospitalization for adults with stroke. Retrospective cohort design using medical records from 2015 to 2016. Major urban hospital. Patients admitted to the stroke service, with a confirmed stroke, who were seen by a physical or occupational therapist; who had a 6 Clicks Basic Mobility or Daily Activity score at initial evaluation; and who were discharged to home, an acute inpatient rehabilitation facility (IRF), or a subacute skilled nursing facility (SNF). Length of stay and discharge destination. Seven hundred four participants (M age = 68.28 yr; 51.21% female) were included. Analysis of variance and receiver operating characteristic curves were performed. Daily Activity scores were highest for home discharge, lower for IRF discharge, and lowest for SNF discharge; Basic Mobility showed a similar pattern. Cutoff values distinguishing home from further inpatient rehabilitation were 44.50 for Basic Mobility and 39.40 for Daily Activity scores (area under the curve [AUC] = .82 for both forms), with scores of 34.59 (AUC = 0.64) and 31.32 (AUC = 0.67) separating IRF from SNF, respectively. Therapists should incorporate 6 Clicks scores into their discharge planning. What This Article Adds: This research demonstrates the utility of an outcome measure in the acute care setting that assists in planning discharge destination for patients with stroke.

ObjectiveTo examine the occurrence and severity of co-occurring traumatic brain injury (TBI) in persons with traumatic spinal cord injury (SCI), i.e. dual diagnosis (DD), and to describe differences in functional outcomes between persons with DD and SCI only from an inpatient rehabilitation facility (IRF) perspective.DesignRetrospective clinical chart review.SettingAcute Midwest SCI inpatient rehabilitation facility.Participants256 persons age 18-80 years with acute traumatic SCI (AIS A-E, C1-S3 level of injury) from 2002-2012.InterventionsNeuroimaging and electronic medical records were reviewed to identify those with co-occurring TBI. Outcomes were then compared between the SCI only and DD groups.Outcome MeasuresLength of stay (LOS), discharge location and functional independence measures (FIM)ResultsForty-one percent of persons with traumatic SCI experienced co-occurring TBI. Rehabilitation LOS for the DD groups did not differ significantly from the SCI only group. Those with Moderate-Severe DD had significantly lower Total admission FIM (P < 0.001), Cognitive admission and discharge FIM (both P < 0.001) and Motor FIM efficiency scores (P = 0.03) compared to those with SCI only and were significantly less likely to discharge home (P = 0.05).ConclusionsPersons admitted to IRFs with Moderate-Severe DD compared to those with SCI only are less efficient in obtaining motor skills and may require ongoing rehabilitation to safely return home. It is therefore imperative to initiate early discharge planning and educate rehabilitation team members and families on the additional time and resources necessary to achieve more successful outcomes in those with Moderate-Severe DD.

A coordination project for improvement of osteoporosis medication use among patients who sustained an osteoporotic fracture: The Israeli experience