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Final Report

Final Report. The Stroke Rehabilitation Pilot Project of SEO This project was funded by the Ontario Ministry of Health, Long Term Care Cally Martin BScPT, MSc (Rehab) John Paterson BEd, MSc (Rehab). The Ontario Stroke Strategy. Patient and Family Continuum of care. Emergency. Acute.

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Final Report

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  1. Final Report The Stroke Rehabilitation Pilot Project of SEO This project was funded by the Ontario Ministry of Health, Long Term Care Cally Martin BScPT, MSc (Rehab) John Paterson BEd, MSc (Rehab)

  2. The Ontario Stroke Strategy Patient and Family Continuum of care Emergency Acute Pre-hospital Transition Prevention REHAB Community Stroke recognition VISION To ensure that all Ontarians have access to the best possible quality stroke care, from prevention, through treatment and rehabilitation, to community re-integration.

  3. H H H H H H H H H H Southeastern Ontario Region H Population 565,500 12,500 miles2 20,000 km2 NORTHUMBERLAND

  4. The Discharge Link Project (DLP) Goal To investigate best practice related to stroke client transition from inpatient rehabilitation to the community by: • enhancing therapy • augmenting provider communication

  5. The DLP Process • Participants included: • Adults with new stroke • Recently discharged from inpatient rehab • Require home care • Going home or to residential setting • Excluded: • Those going to LTC

  6. The DLP Process The Enhanced Therapy (first 2 mths) • Pre-Discharge Link Meeting (OT to OT) • Post-Discharge OT & PSW meeting • Month 1 • up to 2 extra visits/wk OT, PT and/or SLP • +5 hours extra PSW/wk • Month 2 • up to 1 extra visit/wk OT, PT and/or SLP • Allocation to group: ability of CCAC to provide enhanced service

  7. The DLP Process Evaluation • Function: • FIM (CIHI-NRS) at Rehab Admission and Discharge, 3, 6 & 12 mos after discharge • RNL and Health Status at 3mos • Client satisfaction survey • Key Informant Interviews & focus groups • CCAC workload • Hospital readmissions Qualitative and quantitative analysis

  8. Total of 61 (24 U + 37 E) Groups were well matched Community Care Access Centre Usual care group Enhanced therapy group Totals Hastings and Prince Edward (HPE) 6 12 18 Kingston, Frontenac, Lennox & Addington Counties (KFL&A) 8 13 21 Lanark, Leeds and Grenville (LLG) 10 12 22 Totals 24 37 61 DLP Distribution of Participants

  9. DLP Severity of Stroke FRG = Functionally Related Group (at Admission) Based on ratio of motor and cognitive sub-scores on the FIM

  10. Stroke FRGs Organized into Upper, Middle & Lower Bands

  11. DLP: LOS and Wait Times Total time post onset U=106.5E=96.7

  12. DLP: Community Provider Service(First 2 months, incl. 12 Link Meetings)

  13. DLP: Functional Recovery intervention

  14. DLP: Functional Recovery between Discharge and 3 mths

  15. DLP: Change in Recovery

  16. Regression Analysis The most significant predictors of the improved change in function were: 1. FIM score at Discharge p = 0.004* 2. Rehab Care Professional Visitsp = 0.169# * significant at p<0.05 # evidence of contribution to the model

  17. DLP: Hospital Readmissions U(24) E (37) • Re-hospitalizations 11(46%) 9(24%) • Total bed-days 133 73 • Ave days per stay 8.3 6.1

  18. Usual Care Group Fall, multiple fractures Fall, Pelvic fracture TIA, Seizure Pneumonia Infection Heart Condition Enhanced Care Group Knee replacement Hip replacement Bypass Surgery TIA, Seizure Pneumonia Infection Heart Condition DLP: Reasons for Readmissions

  19. DLP: Hospital Readmissions - Costs

  20. DLP: Cost Comparisons

  21. Key informant interviews:Voices of Providers…. “You get so used to working within a system that you … you forget that there might be something better out there...” “I finally get to do real OT!” “A cycle of discontinuity”

  22. Key informant interviews:Voices of clients…. “I am totally overwhelmed” “Horrific” “Hell on earth” “It was hard. It was tough” “if spouses become therapists… it really degrades and demises the personal relationship.” “What do you do?”

  23. DLPRecommendations • Provide enhanced & timely professional therapy for stroke clients • Consider priority setting for those recovering from new stroke • Increase system responsiveness and flexibility • Establish a formal process for coordination of care • Promote models of care that promote client recovery

  24. DLPRecommendations, p2 • Investigate strategies to recruit and retain professional services and promote stable provider workforce • Provide stroke rehab education to CCAC, professional staff and PSWs • Explore role of OT, PT communication assistants • Support caregivers • Regional planning

  25. Thank you! • The Ontario Ministry of Health, Long-Term Care for funding the project • The Rehab subcommittee • CCACs and Hospitals of SEO • Care providers • Clients, Caregivers/Family

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