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Outpatient and Community-Based Stroke Rehabilitation (Including ESD)

2016 UPDATE
February 2016

The Canadian Stroke Best Practice Recommendations for Stroke Rehabilitation, 5th Edition (2015) is published in the International Journal of Stroke (IJS) and available freely online. To access the specific recommendations for Outpatient & Community Based Stroke Rehabilitation (including Early Supported Discharge), and all other sections of the Stroke Rehabilitation recommendations, please click on this URL which will take you to the recommendations online in the IJS: http://journals.sagepub.com/doi/pdf/10.1177/1747493016643553

For the French version of these recommendations, open the appendix at this link :  http://wso.sagepub.com/content/suppl/2016/04/18/1747493016643553.DC1/Stroke_Rehabilitation_2015_IJS_Manuscript_FINAL_FRENCH.pdf

All other supporting information, including performance measures, implementation resources, evidence summaries and references, remain available through www.strokebestpractices.ca, and not through the IJS.  Please click on the appropriate sections on our website below for this additional content.

Rationale

Some patients with mild impairments can be safely transferred back to their homes to continue their rehabilitation and achieve outcomes that are as good as or better than those that would have been attained had they remained in hospital. This form of service provision, known as early-supported discharge (ESD) may be desirable where resources exists and may have the added benefit of being less costly.

Many patients who have completed a course of inpatient rehabilitation will still require ongoing therapy provided in the community to achieve their desired goals once discharged from hospital. Community-based rehabilitation may be defined as care received once the patient has passed the acute stage and has transitioned back to their home and community environment. In smaller communities and rural and remote settings, access to outpatient and/or community rehabilitation presents a significant challenge, and as such, innovative measures such as in-home therapy and telemedicine technology should be utilized.

The evidence suggests that community reintegration takes up to one year post-stroke and individuals make the most gains within the first 6 months post-stroke.

System Implications

There is a marked lack of available outpatient and community-based rehabilitation resources. Therefore, the health system should aim to provide the following:

  • Timely access to stroke rehabilitation services in the community following discharge.
  • Organized and accessible stroke care in communities, including for patients with communication challenges.
  • Increased numbers of skilled clinicians who have experience practicing in outpatient and community rehabilitation.
  • Optimization of strategies to prevent the recurrence of stroke, including regular screening for stroke risk factors and use of standardized screening tools.
  • Stroke rehabilitation support for caregivers to increase patient/caregiver understanding of rehabilitation plans and improve adherence.
  • Long-term rehabilitation services widely available, and without financial barriers, in nursing and continuing care facilities, and in outpatient and community programs, including in-home visits.
  • Increased use of telemedicine technologies to broaden access to outpatient rehabilitation services.
  • Mechanisms for prospective data collection for evaluation and monitoring. All programs should have these in place or be developing them.

Performance Measures

  1. Percentage of stroke patients discharged to the community who receive a referral for ongoing rehabilitation before discharge from hospital (acute and/or inpatient rehabilitation) (core).
  2. Median length of time between referral for outpatient rehabilitation to admission to a community rehabilitation program.
  3. Frequency and duration of services provided by rehabilitation professionals in the community.
  4. Magnitude of change in functional status scores, using a standardized measurement tool, for stroke survivors engaged in community rehabilitation programs.
  5. Length of time between referral for ongoing outpatient/community rehabilitation to commencement of therapy.
  6. Percentage of persons with a diagnosis of stroke who receive outpatient or community-based therapy following completion of a hospital admission to hospital for an acute stroke event.
  7. Percentage of persons receiving ambulatory rehabilitation assessment, follow-up and treatment in all districts/sections/communities served by the stroke rehabilitation service/program. (This would include telehealth, clinic, in-home).
  8. Number of stroke patients assessed by physiotherapy, occupational therapy, speech–language pathologists and social workers in the community.
  9. Use of health services related to stroke care provided in the community for stroke rehabilitation, including timing and dose of services.

Measurement notes

  • Many performance measures require targeted data collection through audits of rehabilitation records and community program records. Documentation quality may create concerns about data availability and data quality.
  • For performance measure 3, information regarding frequency and duration of services by rehabilitation professionals requires a chart review or consistent use of reliable workload measurement tools that are implemented locally or regionally. This data should include the total number of visits or therapy sessions by discipline that the patient receives over a defined time frame (such as first 6 weeks post stroke) and the median length of each session.
  • Data availability regarding community programs varies considerably across programs, regions and provinces. Efforts should be made to introduce standard audit tools for collection of these data.
  • FIM® Instrument data is available in the National Rehabilitation Reporting System (NRS) database at the Canadian Institute of Health Information (CIHI) for participating organizations.

Implementation Resources and Knowledge Transfer Tools

Health Care Provider Information

Patient Information

Summary of the Evidence, Evidence Tables and References

Evidence Table 4: Outpatient & Community Based Stroke Rehabilitation (including Early Supported Discharge)

Outpatient therapy is often prescribed following discharge from acute in-patient care, in-patient stroke rehabilitation units and/or may be required several months or years later for survivors with ongoing rehabilitation goals. Continuing therapy may include hospital-based “day” hospital programs, community-based programs, or home-based rehabilitation, depending on resource availability and patient considerations.

The Outpatient Service Trialists (2002) identified 14 studies that randomized patients with stroke who, at the time of recruitment, were living at home prior to stroke and were within 1 year of stroke onset, to receive specialized outpatient therapy-based interventions or usual care (often no additional treatment). Service interventions examined included those that were outpatient based (home-based n=2, day hospital or outpatient clinic n=12). In these trials, provision of services included physiotherapy, occupational therapy services or interprofessional staff working with patients primarily to improve task-oriented behaviour and hence increase activity and participation. Outpatient therapy was associated with a reduced odds of a poor outcome (OR=0.72 95% CI 0.57–0.92; p=0.009) and increased personal activity of daily living scores (SMD=0.14, 95% CI 0.02–0.25; p=0.02). For every 100 residents with stroke in the community receiving therapy-based rehabilitation services, 7 (95% CI 2–11) patients would be spared a poor outcome, assuming 37.5% would have had a poor outcome with no treatment. The authors concluded that therapy-based rehabilitation services targeted toward stroke patients living at home appear to improve independence in personal activities of daily living. There is also some evidence that quality of life improves following outpatient rehabilitation. In a recent systematic review by Fens et al. (2013), the authors identified two trials that assessed quality of life and reported favourable effects associated with outpatient rehabilitation for up to 3 months post discharge home.

In studies that provided additional occupational therapy (OT) as a sole therapy to patients within 6 months of stroke who were living at home, the results from studies are mixed. Sackley et al. (2006) randomized 118 patients with moderate to severe stroke (Barthel Index [BI] scores of 4–15) who had been admitted to 12 nursing homes to receive a 3 month occupational therapy (OT) program that was client-centred and targeted towards independence in ADL, or to receive no OT. At 6 months, although there were no significant differences between groups in terms of improvement in BI or Rivermead Mobility Index scores, significantly fewer patients in the OT group had a poor global outcome (51% vs. 76%, p=0.03), defined as deterioration of BI scores or death. In a trial that randomized 138 patients who planned to return home following discharge from hospital, to receive either 6 weeks of domiciliary OT or to receive routine post-stroke follow-up care, there were significantly improved outcomes for approximately half of the outcomes assessed. There were no significant differences at 6 months between groups for Nottingham EADL scores (primary outcome), BI or London Handicap scores. There were significant differences favouring the OT group for selected components of Canadian Occupational Performance Measure (COPM) and Dartmouth COOP Charts (Gilbertson et al. 2000, Gilbertson & Langhorne 2000). When 185 patients who had sustained a stroke within the previous 6 months and had not have been admitted to hospital received outpatient OT for up to five months, there were significantly greater improvements in Nottingham EADL scores at 6 months and one year, compared with patients in the control group who received usual care (Walker et al. 1999).

There is some evidence that patients who receive outpatient rehabilitation in their homes may have better short-term outcomes compared with those who received services in a day hospital or clinic setting. A systematic review and meta-analysis (Hillier & Inglis-Jassiem 2010) compiled the results from 11 RCTs that included patients who were discharged from inpatient rehabilitation to home following a stroke and who had been living in the community prior to the event. Home-based therapy was associated with a 1-point mean difference in BI gain at 6–8 weeks following the intervention and a 4-point difference at 3–6 months. By 6 months following treatment, there were no longer significant differences between groups. The majority of the trials that have examined the comparison between home and community-based and hospital-based rehabilitation programs have failed to identify the superiority of one service provision model over the other. The interventions most commonly assessed were physiotherapy and/or occupational therapy and the outcomes usually included scales of ADL or extended ADL performance, gait speed and/or quality of life (Young & Forester, 1992, Gladman et al. 1993, 1994, Lincoln et al. 2004, Bjorkdahl et al. 2006). In a trial evaluating the benefit of hospital vs. community-based physiotherapy for patients whose rehabilitation goals included independent ambulation, while patients in both groups had improved after a 7-week program, there were no differences between groups in gait speed or performance on the 6MWT (Lord et al. 2009).

There is also high-quality evidence that rehabilitation in the home or community is less costly than inpatient rehabilitation. In a recent systematic review and meta-analysis, Brusco et al. (2014) identified four studies (n=732) comparing the cost of inpatient rehabilitation to that of home or community-based rehabilitation for patients with moderate to severe stroke. Based on these results, inpatient rehabilitation was found to be more costly, as compared to outpatient programs offered at home, with an overall effect size of 0.31 (95% CI 0.15–0.48) (Brusco et al. 2014).

Early Supported Discharge

Early-supported discharge (ESD) is a form of rehabilitation designed to accelerate the transition from hospital to home through the provision of rehabilitation therapies delivered by an interprofessional team, in the community. It is intended as an alternative to a complete course of inpatient rehabilitation and is most suitable for patients recovering from mild to moderate stroke. An argument in favour of ESD programs is that, since the goal of rehabilitation is to establish skills that are appropriate to the home setting, the home provides the optimal rehabilitation environment. Key components of ESD that have been reported as contributing to favorable outcomes include: 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.

Patients who are recovering from mild strokes and are recipients of ESD programs have been shown to achieve similar outcomes compared with patients who receive a course of inpatient rehabilitation. The effectiveness of ESD programs following acute stroke has been evaluated most comprehensively by the Early Supported Discharge Trialists. In the most updated version of the review (Fearon et al. 2012), the results from 14 RCTs were included. The majority of the trials evaluated ESD using a multidisciplinary team which, coordinated discharge from hospital, and provided rehabilitation and patient care at home. ESD was associated with a reduction in the odds of death or the need for institutional care (OR=0.78, 95% CI 0.61 to 1.00, p=0.049), death or dependency, (OR=0.82, 95% CI 0.67 to 0.97, p=0.021) improvement in performance of extended ADL (SMD=0.14, 95% CI 0.02 to 0.26, p=0.024) and satisfaction with services (OR=1.6, 95% CI 1.08 to 2.38, p=0.019). The ESD groups showed significant reductions (p<0.0001) in the length of hospital stay equivalent to approximately eight days. There were no significant differences between groups on the outcomes associated with patients’ carers (subjective health status, mood or satisfaction with services).

Langhorne et al. (2005) 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. The levels of service provision evaluated were: (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.

Home Exercise Programs

The effectiveness of home-based exercise programs for mobility improvement was recently the subject of a Cochrane review (Coupar et al. 2012). The results from four RCTs (n=166) examining home-based therapy program targeted at the upper limb were included. The effectiveness of therapy was compared with usual care in three studies (Duncan et al. 1998, 2003; Piron et al. 2009). The primary outcomes were performance on ADL and functional movement of the upper limb. The results were not significant for both outcomes (MD 2.85 95% CI -1.43–7.14 and MD 2.25 95% CI -0.24–4.73, respectively). No significant treatment effect was observed for secondary outcome measures as well (performance on extended ADL and upper limb motor impairment). The authors concluded that there was insufficient evidence to draw conclusions regarding the effectiveness of home-based therapy programs compared to usual care.

A number of individual trials, not included in the aforementioned Cochrane review, compared the effectiveness of home-based therapy with usual care, placebo, or no intervention. Nadeau et al. (2013) randomized 408 patients admitted to inpatient rehabilitation within 45 days of stroke, to receive locomotor training program (LTP), home exercise program (HEP), or standard care, for up to 12 to 16 weeks. Both LTP and HEP groups improved significantly in functional walking level and balance, compared to the usual therapy group, with no significant difference separating the two treatment groups. Harris et al. (2009) compared the effectiveness of home-based self-administered program to that of non-therapeutic education program and found significant treatment-associated effects on paretic upper limb performance, which was maintained for up to 3 months post treatment. In a RCT by Langhammer et al. (2007), the intensive exercise group demonstrated significantly greater improvements in motor assessment scale from admission to discharge from acute care, as well as from 6 months to 1 year post stroke, compared with the regular exercise group.