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Stroke Rehabilitation Rebuilding a life

Stroke Rehabilitation Rebuilding a life. Marla Rose, Speech Language Pathologist Trinity Hospital. Objectives. Discuss the multiple levels of rehabilitation T herapeutic services provided from acute care to home. Therapeutic rationale for intervention and for discharge planning.

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Stroke Rehabilitation Rebuilding a life

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  1. Stroke RehabilitationRebuilding a life Marla Rose, Speech Language Pathologist Trinity Hospital

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

  3. Who 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.

  4. Trinity Hospital - 2011 • 165 admitted with stroke as primary diagnosis • 83% Ischemic • 11% Intracerebralhemorrahage • 5% Subarachnoid hemorrhage • Average age: 70.5 years • Discharge disposition • 42% Home • 23% Inpatient rehab • 13% SNF • 7% Expired

  5. Rebuilding a life • Stroke is the leading cause of serious, long-term disability in the United States.

  6. ROAD TO RECOVERY

  7. Recovery 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

  8. Multiple Levels of Rehabilitation Home – Independent Home + Outpatient tx Home + Home Care Skilled Nursing Facility Inpatient Rehab Acute Care

  9. Factors 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

  10. Rehabilitation team • Patient and family • Physicians • Physical Therapist • Occupational Therapist • Speech-language Pathologist • Nurses • Dietician • Social Worker • Orthotist • Mental Health • Insurance Company • Community Resources

  11. Acute CareAcute 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

  12. Acute CareAcute 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

  13. Acute Care • 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

  14. Acute Discharge 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; 3rd party payer.

  15. Rehabilitation Theory • 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

  16. Rehabilitation Theory • 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

  17. Rehabilitation 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.

  18. Medicare’s Expectation • 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.

  19. Inpatient rehab Trinity Hospital – St. Joseph’s Campus

  20. Inpatient rehabWhat you Need 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

  21. Admit Severity: How 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.

  22. 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

  23. Inpatient rehabhow is it different • Therapy intensity • Mandatory participation • Therapy staff • Social Worker • Medical director – visits patients daily • Nursing staff and the scope of their responsibilities

  24. Medical Complications • Pulmonary aspiration, pneumonia – 40% • Urinary tract infection – 40% • Depression – 30% • Musculoskeletal pain – 30% • Falls – 25% • Malnutrition – 16% • Venous thromboembolism 6% • Pressure ulcer – 3%

  25. Nursing Staff • They’re not ONLY nurses • They’re NURSE THERAPISTS

  26. Inpatient Rehab Nursing Staff • 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.

  27. Inpatient Rehab Outcomes 2011 2007 • # of stroke patients 51 72 • Average Age 72 73 • ALOS (days) 13 14 • D/C Home 80% 74% • D/C SNF 16% 17% • Ave FIM gain points 28 22 (target: 28 points)

  28. Physical Therapy • Exercises to address the sensory-motor physiology • Apply the physiological gains to functional ADLs

  29. Occupational Therapy • Exercises to address the sensory-motor physiology • Apply the physiological gains to functional ADLs

  30. Speech-Language Pathology • Exercises to address the sensory-motor physiology of swallowing • Apply the physiological gains to functional swallow

  31. Speech-Language Pathology • Exercises to address neurological processing and/or physiology for communication skills • Apply gains to functional communication interactions

  32. Skilled Nursing Facility • 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

  33. Skilled Nursing Facility • 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

  34. Home with Home Care • Scenario # 1 • Patient discharged from inpatient rehab with recommendations to continue therapy. • Scenario #2 • Patient discharged from acute care with recommendations for therapy.

  35. Home with Home Care • 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

  36. Home with Outpatient Therapy • 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.

  37. Home with Outpatient Therapy • 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

  38. Through all levels of rehabilitation • Patient goals • Medicare/3rd party payer expectations • Neuroplasticity theory • Target actual functional use BEFORE compensatory training

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