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NEW Stroke Rehabilitation Planning for Optimal Care Delivery
NEW Stroke Rehabilitation Planning for Optimal Care Delivery

4. Outpatient & Community Based Rehabilitation, and Early Supported Discharge

Note

These recommendations apply to all individuals with stroke who are assessed by healthcare professionals following a stroke event, treated by primary care, or at a stroke prevention clinic, emergency department, urgent care centre, inpatient acute care or inpatient rehabilitation setting, and discharged back to the community.

Recommendations and/or Clinical Considerations
4.1 Outpatient & In-Home Rehabilitation
  1. Individuals with stroke who have ongoing rehabilitation goals should continue to have access to specialized stroke services after leaving hospital [Strong recommendation; High quality of evidence].  
    1. This should include healthcare facility-based outpatient services and/or in-home rehabilitation services, and virtual stroke rehabilitation [Strong recommendation; High quality of evidence].  
  2. Outpatient and/or in-home rehabilitation services should be provided by interdisciplinary team members with appropriate training and expertise [Strong recommendation; High quality of evidence], based on the individual needs and in consultation with the individual with stroke, their family and caregivers [Strong recommendation; Moderate quality of evidence]. 
    1. Services should ideally begin within 48 hours of discharge from an acute hospital (emergency department or inpatient) or within 72 hours of discharge from inpatient rehabilitation [Strong recommendation; Low quality of evidence].
  3. Outpatient and/or in-home rehabilitation service delivery should be delivered in a setting that best meets the needs of the individual, and consider functional rehabilitation needs, participation-related goals, availability of family/social support, individual and family preferences where appropriate [Strong recommendation; Low quality of evidence]. 
  4. Outpatient and/or in-home rehabilitation services should include the same elements as coordinated inpatient rehabilitation services [Strong recommendation; Moderate quality of evidence].  This includes: 
    1. Involvement of individuals with stroke, their family and caregivers in recovery planning, rehabilitation management, goal setting, and transition planning [Strong recommendation; Moderate quality of evidence].
    2. An interdisciplinary stroke rehabilitation team [Strong recommendation; High quality of evidence].
    3. A case coordination approach including regular team communication to discuss assessment of new clients, review client management, goals, and plans for discharge or transition [Strong recommendation; Moderate quality of evidence].
    4. Therapy provided for 60 minutes per session per required discipline [Strong recommendation; Moderate quality of evidence], for 2 to 5 days per week, [Strong Recommendation; Moderate quality of evidence]. 
    5. Interdisciplinary care planning and communication is essential to ensure continuity of care, individual with stroke safety, and to reduce risk of complications and adverse events during stroke care particularly at transition points [Strong recommendation; Moderate quality of evidence].
  5. At any point in their recovery, individuals with stroke who have experienced a change in functional status and who would benefit from additional rehabilitation services should be offered a further period of rehabilitation in the setting best suited to their needs if they meet the requirements outlined in Box 1: Eligibility Criteria for Stroke Rehabilitation [Strong recommendation; Moderate quality of evidence].

Section 4.1 Clinical Consideration:

  1. The duration of outpatient and/or in-home rehabilitation services should be based on the rehabilitation needs and goals of the individual with stroke, and progress towards those over time.
4.2 Early Supported Discharge (ESD)
  1. For individuals with mild or moderate stroke, early supported discharge should be considered where appropriate and services are available to provide the recommended intensity of therapy [Strong recommendation; High quality of evidence]. Refer to Box 4 for criteria for ESD. 
  2. Early supported discharge services should be provided by a well-resourced, coordinated, interdisciplinary specialized team [Strong recommendation; High quality of evidence]. 
  3. Early supported discharge services should be provided within 48 hours of discharge from an acute hospital or within 72 hours of discharge from inpatient rehabilitation [Strong recommendation; Moderate quality of evidence]. 
  4. Services should be provided five days per week at the same level of intensity as they would have received in the inpatient setting to meet individual with stroke needs [Strong recommendation; Moderate quality of evidence]. Refer to Section 3 ii, Delivery of Inpatient Stroke Rehabilitation, for additional information.
    1. Where possible, ESD should be provided by the same team that provided inpatient rehabilitation to ensure a smooth transition [Strong recommendation; Moderate quality of evidence].
    2. Where different therapists are providing ESD services, communication with the hospital-based rehabilitation team is important during the transition.  Processes to facilitate clear and timely communication should be implemented and appropriate meetings scheduled to ensure continuity of care [Strong recommendation; Low quality of evidence].
Rationale +-

Early supported discharge (ESD) following a stroke is an effective model of care that facilitates an individual’s transition from hospital to home as soon as they are medically stable, while still receiving intensive rehabilitation and support. This approach involves an interdisciplinary team, working together to provide tailored care and rehabilitation in the home environment. ESD has been shown to promote faster recovery, improve satisfaction, and reduce hospital readmissions, as well as being less costly. Individuals with stroke often experience less stress and a greater sense of independence when in their own home, while alleviating pressure on hospital resources by freeing up beds for others. Importantly, the home environment provides unique opportunities to address real-life challenges and re-establish daily routines, enhancing the functional recovery process and overall quality of life for stroke survivors.

Many individuals with stroke 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 provided as hospital-based clinics and programs (e.g., day hospital), community clinics or programs, or through privately owned and operated rehabilitation facilities. In smaller communities where access to outpatient and/or community rehabilitation services are limited, in-home therapy and virtual care digital technology can also be utilized. 

Individuals with stroke emphasized that community stroke rehabilitation services, including psychological and mental health services, should be available for all those who have ongoing rehabilitation goals. They identify the difficulties with access to services and resources once they are back in the community, and the challenge of re-accessing rehabilitation services in the community should they be required, including lack of information on how to re-access services and who to contact. Furthermore, individuals with stroke emphasized the importance of education relating to available community supports and resources that is tailored to their needs and goals, as well as access to peer support groups. Individuals with stroke also expressed how they would have appreciated more follow-up after returning to the community, and regular follow-ups thereafter.

Performance Measures +-

System indicators:

  1. Proportion of individuals with stroke who receive outpatient or community-based therapy following discharge from an acute stroke admission.
  2. Proportion of persons receiving outpatient/community-based 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).
  3. Frequency and duration of services provided by rehabilitation professionals in the community.
  4. Use of health services related to stroke care provided in the community for stroke rehabilitation, including timing and frequency and duration of services.

Process indicators:

  1. Proportion of individuals with stroke discharged to the community who receive a referral for ongoing rehabilitation before discharge from hospital (acute and/or inpatient rehabilitation).
  2. Median length of time between referral for outpatient rehabilitation to first appointment for assessment and therapy.
  3. Number of individuals with stroke assessed by physiotherapy, occupational therapy, speech–language pathologists and social workers as needed in outpatient and community settings.

Patient-oriented indicators:   

  1. Magnitude of change in functional status scores from admission to stroke rehabilitation to discharge, using a standardized measurement tool, for individuals with stroke engaged in outpatient and community rehabilitation programs.
  2. Measure of burden of care for family and caregivers of individuals with stroke living in the community and change in burden scores at 3 months, 6 months and one year following discharge from hospital for an acute stroke.
Implementation Resources and Knowledge Transfer Tools +-

Resources and tools listed below that are external to Heart & Stroke and the Canadian Stroke Best Practice Recommendations may be useful resources for stroke care. However, their inclusion is not an actual or implied endorsement by the Canadian Stroke Best Practices or Heart & Stroke. The reader is encouraged to review these resources and tools critically and implement them into practice at their discretion.

Healthcare Provider Information

Resources for Individuals with Stroke, Families and Caregivers

Summary of the Evidence +-

Evidence Table and Reference List

Outpatient Rehabilitation

Outpatient therapy is often required following discharge from acute and/or rehabilitation inpatient services to help individuals with stroke continue to make gains towards their rehabilitation goals. Continuing therapy may take several forms, depending on resource availability and individual considerations and include such models as hospital-based “day” hospital programs, community-based programs, or home-based rehabilitation. There is strong evidence that any form of continuing rehabilitation therapy is superior to no additional therapy. The Outpatient Service Trialists, published in 2003,36 which has not been updated, identified 14 RCTs that included individuals with stroke who were living at home prior to their stroke and whose stroke had occurred within the previous year. In 12 of these trials, participants were recruited from a hospital setting, while in the remaining two trials, participants were recruited from home. Individuals with stroke were randomized to receive specialized outpatient therapy-based interventions or usual care (often no additional treatment). Service interventions examined included those that were home-based (n=2), day hospital or outpatient clinics (n=12). In these trials, provision of services included physiotherapy, occupational therapy services or interprofessional staff, aimed primarily at improving performance in activities of daily living (ADL). Therapy duration in these trials ranged from 5 weeks to 6 months. At the end of scheduled follow-up (mean of 3-12 months), outpatient therapy was associated with reduced odds of a poor outcome, defined as deterioration in ability to perform ADLs, dependency or institutionalization (OR=0.72 95% CI 0.57–0.92; p=0.009) and with small, but significantly greater improvements in ADL, extended ADL and mood scores compared with usual care (standardized mean difference [SMD]=0.14, 95% CI 0.02–0.025; p=0.02, SMD=0.17, 95% CI 0.04–0.30; p=0.01 and SMD=0.11, 95% CI -0.04–0.26; p=0.02, respectively). The authors estimated that for every 100 persons with stroke in the community receiving therapy-based rehabilitation services, 7 (95% CI 2–11) patients would avoid a poor outcome, assuming 37.5% would have had a poor outcome with no treatment. A more recent systematic review authored by Chi et al. 37 included the results from 49 RCTs comparing home-based rehabilitation therapies (occupational and physical therapy) provided with the aim of improving physical function vs. usual care, no care or active control, with a focus on ADL training. Home-based rehabilitation was associated with a moderate improvement in function (Hedges’ g=0.58; 95% CI, 0.45-0.70). Younger age, male sex, and first-ever acute stroke episode were variables associated with greater improvements.

In terms of establishing the relative superiority of outpatient-based rehabilitation programs compared with continued inpatient services, the differences between service models appears minimal.  In a systematic review, Hillier & Inglis-Jassiem38 included the results of 11 RCTs of 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 Barthel Index [BI] gain at 6–8 weeks following the intervention and a 4-point difference at 3–6 months, compared with hospital-based rehabilitation. By 6 months following treatment, there were no longer significant differences between groups. Overall, there were no significant differences in outcomes reported in 4 of the included trials, with some benefits noted in favour of home-based therapy reported in 7 trials (lower cost, less carer strain, lower readmission). No trials reported any benefits in favour of hospital-based rehabilitation. Lincoln et al.39 reported no significant differences between groups randomized to receive hospital-based care (outpatient or day hospital) compared with community stroke teams (CST), staffed with multidisciplinary therapists in measures of ADLs, extended ADLs or Euro-QoL scores with the exception of the emotional support item, favouring the community stroke team group. Carer strain and satisfaction scores were higher in the CST group.

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, as soon as possible following discharge. It is intended as a lower-cost alternative to a complete course of inpatient rehabilitation and is best suited for patients recovering from mild to moderate stroke. Key components of effective ESD programs include in-hospital and discharge planning, a case manager or ‘key worker’ based in the stroke unit who represents the essential link between the stroke unity and the outpatient care, guaranteeing continuity of care and enabling the smooth transition from the hospital to the home. Individuals with stroke who participated in ESD programs have been shown to achieve similar outcomes compared with those who received a course of inpatient rehabilitation. The effectiveness of ESD programs following acute stroke has been evaluated most comprehensively by the Early Supported Discharge Trialists.4 In the most updated version of the review, the results from 17 RCTs were included. The majority of the trials evaluated ESD using a multidisciplinary team which, coordinated discharge from hospital, and provided rehabilitation and care at home. ESD services were associated with a reduction in the odds of death or dependency at end of scheduled follow-up after a median duration of follow-up of 6 months (OR=0.80, 95% CI 0.67 to 0.95). The associated number needed to treat (NNT) per 100 patients was 5. The benefits were greatest among patients with mild-moderate disability. ESD services were also associated with slightly greater improvement in extended ADL performance (SMD= 0.17, 95% CI 0.04-0.30), greater satisfaction and a significantly shorter hospital LOS (mean difference [MD]=-5.5, 95% CI -2.9 to -8.2 days). A more recent systematic review,40  included the results from 20 RCTs, all published after 1997, in which patients were randomized to receive either conventional care or any care service intervention that included rehabilitation or support provided by professional medical personnel with the aim of accelerating and supporting home discharge. ESD programs were not associated with a significant reduction in hospital LOS (SMD=-0.13, 95% CI −0.31 to 0.04 days), improvement in ADLs (SMD=0.79, 95% CI -0.04-1.18), or a reduction in caregiver strain. The authors suggested that the reason for the conflicting results with the Cochrane review 4 may have been due to their tighter inclusion criteria, which excluded patient-led, family-led, and telerehabilitation interventions, and to ceiling effects of the ADL measures used. 

Langhorne et al.41 included data from 11 RCTs in a patient level meta-analysis, which examined the effects of patient characteristics and differing levels of ESD 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; 95% CI 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 (OR=0.70; 95% CI 0.56- 0.88) compared to those without an ESD team. Based on the results of this study, it appears that a select group of patients, with mild to moderately disabling stroke, receiving more coordinated ESD could achieve better outcomes.

Home Exercise Programs

The effectiveness of home-based exercise programs for mobility improvement was the subject of a Cochrane review.42 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.43, 44 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 more recent systematic review 45 came to a similar conclusion. The results from 15 RCTs were included comparing self-administered home-based, structured upper limb practice vs. nonstructured home-based practice or no intervention. Neither structured nor non-structured practice were associated with significant improvement in performance on ADL.

Sex & Gender Considerations

No studies examining potential sex or gender differences in the delivery, or associated outcomes of outpatient rehabilitation or early supported discharge programs, were retrieved.

Stroke Resources
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