Early Supported Discharge

Stroke survivors should continue to have access to specialized stroke services after leaving hospital, whether from acute care or inpatient rehabilitation [Evidence Level A].

Early supported discharge services provided by a well resourced, coordinated specialized interprofessional team are an acceptable alternative to more prolonged hospital stroke rehabilitation unit care and can reduce the length of hospital stay for selected patients [Evidence Level A].
Stroke patients with mild to moderate disability may be offered early supported discharge if all of the following criteria are met:
1. They are able to participate in rehabilitation from the date of transfer [Evidence Level B].
2. They can be safely managed at home [Evidence Level B].
3. They have access to comprehensive interprofessional community rehabilitation services and caregiver or support services [Evidence Level A].
Early supported discharge should not be offered to patients with moderately severe to severe stroke [Evidence Level A].
To work effectively, early supported discharge services must have elements similar to those of coordinated inpatient stroke teams including:
1. A case coordination approach [Evidence Level B].
2. An inter-professional team of specialists in stroke care and rehabilitation working in collaboration with community-based healthcare professionals [Evidence Level B].
3. Emphasis on client- and family-centered practice, setting client goals and ongoing review of goal attainment [Evidence Level C].
4. Stroke rehabilitation services with intensity established based on individual client needs and goals [Evidence Level B].
5. Services that are delivered in the most suitable environment based on client issues and strengths [Evidence Level C].
6. Regular team meetings to discuss assessment of new clients, review client management, goals, and plans for discharge [Evidence Level A].
7. Family meetings to ensure patient and family involvement in management, goal setting, and planning for discharge from the early supported discharge program [Evidence Level A].
8. Negotiated withdrawal and discharge from early supported discharge program [Evidence Level C].

Rationale

Early supported discharge is a model of care that links inpatient care with community rehabilitation and other services. Patients are often discharged home after a shorter length of hospital stay and receive an intensive program of rehabilitation within their home environment. Skills learned once the patients are home may be better retained since they are in the real-life environment compared to learning similar skills in hospital. Successful early supported discharge programs have reported better patient outcomes and reduced readmissions to hospital.

System Implications

Dedicated resources for a specialized interprofessional team who provide rehabilitation services to patients immediately following discharge.
Early supported discharge services that have similar elements and membership as those of organized stroke teams.
Early supported discharge services targeting stroke survivors with mild to moderate disability, and considered only where there are adequate community services for rehabilitation and caregiver support.

Performance Measures

Readmission rates to acute care for patients discharged to the community with an early supported discharge program (within 30 days and 90 days).
Patient’s and/or family’s experience and satisfaction with care received.
Provider’s experience and satisfaction with the quality of interaction and collaboration among providers involved in care transitions.
Change in functional status from discharge from hospital to discharge from early supported discharge program.

Measurement Notes

Readmission rates for early supported discharge patients should be compared to patients from the same facility or region discharged without early supported discharge.
Risk adjustment should include age, gender, and stroke severity. If available co-morbidities should also be included in the models.
Standardized scales, such as the FIM® Instrument, should be used for measuring functional status.

Implementation Resources and Knowledge Transfer Tools

Summary of the Evidence

Early supported discharge has been a controversial topic in the stroke research literature.²⁸ The efficacy of early supported discharge for acute stroke patients was evaluated by the Early Supported Discharge Trialists (2004).⁵²² The purpose of this review was to determine whether early supported discharge, with appropriate community support, could be as effective as conventional inpatient rehabilitation. Early supported discharge interventions were designed to accelerate the transition from hospital to home. Six of the trials provided coordinated interprofessional team care that was provided in the patients’ homes. One trial provided a wide range of services that were not centrally coordinated.⁵²³ A variety of outcomes were assessed comparing early supported discharge with conventional care at the end of scheduled follow-up, which ranged from three months to one year. While early supported discharge programs were associated with shorter periods of initial hospitalization, their impact on the well-being of caregivers remains unknown.

There is strong evidence that stroke patients with mild to moderate disability, discharged early from an acute hospital unit, can be rehabilitated in the community by an interprofessional stroke rehab team and attain similar functional outcomes when compared to patients receiving inpatient rehabilitation.⁵²⁴ A key argument for ESD is that the home provides an optimal rehabilitation environment, since the goal of rehabilitation is to establish skills that are appropriate to the home setting.⁵²⁵Early supported discharge has been found to have similar outcomes for patients with milder strokes, compared to inpatient rehabilitation, although cost saving benefits are less clear. ⁵²⁵

Appropriately resourced ESD services provided for a selected group of stroke patients can reduce long-term dependency and admission to institutional care as well as reducing the length of hospital stay. No adverse impact was observed on the mood or subjective health status of patients or carers. ^525,526This systematic review revealed that recognition of the impact of stroke on patients and carers is improving with many studies focusing on the longer-term aspects of stroke recovery. Earlier discharge may have important implications for those involved. The greatest benefits were seen in the trials evaluating a coordinated interprofessional early discharge team and with patients with mild-moderate disability.

Langhorne and colleagues reported additional patient level analysis from their original Cochrane review, which examined the effects of patient characteristics and differing levels of service provision (more coordinated v. less organized) on the outcome of death and dependency.³⁵² The results from an unpublished study were included in this analysis. The levels of service evaluated were as follows: (1) early supported discharge team with coordination and delivery, whereby an interprofessional team coordinated discharge from hospital and post discharge care and provided rehabilitation therapies in the home; (2) early supported discharge team coordination, whereby discharge and immediate post-discharge plans were coordinated by an interprofessional care team, but rehabilitation therapies were provided by community-based agencies; and (3) no early supported discharge team coordination, whereby therapies were provided by uncoordinated community services or by healthcare volunteers. There was a reduction in the odds of a poor outcome for patients with a moderate initial stroke severity (BI 10-20), (OR= 0.73; 0.57-0.93), but not among patients with severe disability (BI< 9) and also among patients who received care from a coordinated multidisciplinary ESD team (0.70; 0.56- 0.88) compared to those without an ESD team. Based on the results of this study, it would appear that a select group of patients, with mild to moderately disabling stroke, receiving more coordinated ESD could achieve better outcomes compared to organized inpatient care on a stroke unit.

Outcome data reported on a review of 11 trials (1597 patients) found patients tended to be a selected elderly group with moderate disability.^{526, 527} The ESD groups showed significant reductions (P < 0.0001) in the length of hospital stay equivalent to approximately eight days. Overall, the odds ratios (OR) (95% confidence interval (CI)) for death, death or institutionalization, death or dependency at the end of scheduled follow up were OR 0.90, 95% CI 0.64 to 1.27, P = 0.56, OR 0.74, 95% CI 0.56 to 0.96, P = 0.02 and OR 0.79, 95% CI 0.64 to 0.97, P = 0.02, respectively. The greatest benefits were seen in the trials evaluating a coordinated ESD team and in stroke patients with mild-moderate disability. Improvements were also seen in patients' extended activities of daily living scores (standardized mean difference 0.12, 95% CI 0.00 to 0.25, P = 0.05) and satisfaction with services (OR 1.60, 95% CI 1.08 to 2.38, P = 0.02) but no statistically significant differences were seen in carers' subjective health status, mood or satisfaction with services.^{526, 527}

An interesting observation in the trial of the ESD service in Southwest Stockholm (seen at five years follow-up after stroke) was an increased independence in extended ADL, frequency of household activities and a favorable outcome as regards to resource use. ⁵²⁸ Similar benefits were also observed in another study of ESD. By three months after stroke, the home intervention group showed a significantly higher score on the SF-36 Physical Health component than the usual care group. The total number of services received by the home group was actually lower than that received by the usual care group. ⁵²⁹The authors of this study concluded that prompt discharge combined with home rehabilitation appeared to translate motor and functional gains that occur through natural recovery and rehabilitation into a greater degree of higher-level function and satisfaction with community reintegration, and these in turn were translated into a better physical health.

Key components of ESD that have been reported as contributing to favorable outcomes included: in-hospital and discharge planning: a case manager or ‘key worker’ based in the stroke unit who constituted the link between the stroke unity and the outpatient care, guaranteeing continuity in both time and personnel, and enabling the smooth transition from the hospital to the home^526,528; protocols and meetings which ensured that the activities were inter-disciplinary; patient motivation and focusing on more realistic rehabilitation goals; partnership between patient and therapist with significantly more patients receiving the ESD reporting that they were actively involved in planning their rehabilitation; Encouraging more focus on self-directed activities; and, more realistic understanding of future recovery.⁵²⁸

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