Previous Section 4. Outpatient & Community Based Rehabilitation, and Early Supported Discharge Next Section 6. Virtual Stroke Rehabilitation
NEW Stroke Rehabilitation Planning for Optimal Care Delivery
NEW Stroke Rehabilitation Planning for Optimal Care Delivery

5. Stroke Rehabilitation in Long-term Care and Complex Continuing Care

Note

These recommendations apply specifically to individuals with stroke living in long-term care or chronic or continuing care settings, including those who were already living in long-term care at the time of their stroke. These recommendations are intended to be implemented in addition to standard care (e.g. physical, functional, emotional, cognitive, communication and social needs) provided in chronic, continuing or long-term care. Also refer to recommendations included in other modules such as Secondary Prevention of Stroke and Stroke Systems of Care for additional information on management of individuals with stroke living in long-term care settings.

Recommendations and/or Clinical Considerations
5.1 Assessment and Care Planning
  1. All individuals who transition to a long-term or complex continuing care setting following a stroke should have an initial medical and functional assessment as soon as possible after admission [Strong recommendation; High quality of evidence]. Refer to Rehabilitation, Recovery and Community Participation following Stroke Part Two: Delivery of Stroke Rehabilitation to Optimize Functional Recovery, Part Three: Optimizing Activity and Community Participation following Stroke and other sections of this module for information on assessments.
    1. A discharge summary along with the care plan should accompany the individual to a long-term or complex continuing care setting [Strong recommendation; High quality of evidence] Refer to Box 7 regarding information to include in the discharge summary.
    2. The initial assessment of functional, physical, emotional, cognitive, communication and perceptual status should align with existing assessment processes where possible [Strong recommendation; Moderate quality of evidence]. 
  2. Assessment results should be used to modify individualized care plans to meet the rehabilitation needs and goals of individuals who are admitted to long-term or complex continuing care following a stroke and optimize quality of life [Strong recommendation; Moderate quality of evidence].
  3. Individualized care plans should be updated to reflect changes in reassessments, functional status, goals of the individual with stroke, and care requirements and address issues of safety [Strong recommendation; Moderate quality of evidence].
  4. Individuals with stroke living in long-term or complex continuing care setting should be referred to appropriate healthcare professionals for further consultation when changes in functional status are identified during the initial assessment or subsequent existing assessment processes where possible [Strong recommendation; Moderate quality of evidence]. 
  5. Individuals with stroke living in long-term care, complex continuing care and similar settings should receive care from individuals who are knowledgeable in stroke care, maintenance and recovery goals, and therapies aligned to stroke best practice recommendations [Strong recommendation; Moderate quality of evidence]. 
    1. Individuals providing care in these settings should be provided with updated education in these areas on a regular basis [Strong recommendation; Moderate quality of evidence].
5.2 Rehabilitation and Restorative Care
  1. Individuals admitted to a long-term care setting with ongoing rehabilitation goals post-stroke should continue to have access to specialized stroke services (such as physiotherapy, occupational therapy and speech-language therapy) following admission [Strong recommendation; Moderate quality of evidence].
  2. Individuals with stroke who live in long-term or complex continuing care should also have access to other health disciplines and services that can support recovery and restorative care [Strong recommendation; low quality of evidence].
  3. At any point in their recovery, individuals with stroke living in long-term care who have experienced an improvement in functional status and who would benefit from new or additional rehabilitation services should be offered a trial of higher intensity inpatient or outpatient rehabilitation [Strong recommendation; Moderate quality of evidence].
  4. Individuals with stroke living in long-term or complex continuing care should have access to restorative care interventions that foster self-care, social engagement and emotional well-being [Strong recommendation; Moderate quality of evidence].
5.3 Support and Education for the Individual with Stroke, their Family and Caregivers
  1. To facilitate active participation in care-planning in long-term or complex continuing care settings, individuals living with stroke, their family and caregivers should be provided with training, education and support on:
    1. How to advocate for access to rehabilitation and restorative care as appropriate [Strong recommendation; low quality of evidence]. 
    2. How to participate in care planning and be involved in shared decision-making. [Strong recommendation; low quality of evidence]. 
    3. Process for appointing a substitute decision-maker (proxy or agent), developing advance directives for care, and palliative care options as appropriate [Strong recommendation; low quality of evidence].  Refer to Stroke Systems of Care module for additional information on advance care planning and palliative care.
Rationale +-

Healthcare surveillance data indicates that persons with stroke are among the largest population receiving long-term care, and their number is steadily increasing worldwide. The post-discharge period is consistently reported to be a stressful and challenging time for individuals with stroke and their families as they adjust to new roles, altered functional and cognitive abilities, and changes in living setting for people admitted to long-term care following an acute stroke. The transition from hospital to long-term or complex continuing care (LTC/CCC) for individuals with stroke can be a difficult step for those who cannot return to their previous living arrangements in the community as a result of significant impairments or complex medical needs. The move requires careful coordination to ensure continuity of care, with staff who are knowledgeable and competent in caring for both the medical needs and rehabilitation goals of individuals with stroke. This will enable those with stroke to maintain quality of life and dignity and have rehabilitation and recovery goals and plans that focus on restorative care, maintenance of function, support to mitigate and address for health declines, sensitivity to family needs, and provide care by staff knowledgeable in stroke to maximize outcome goals.

Individuals with stroke felt strongly that those living in Long-term Care (LTC) or complex continuing care (CCC) should have the same access to stroke rehabilitation services as others. They emphasized that care plans in LTC/CCC should reflect and address stroke rehabilitative needs and goals. It can be difficult for those living in LTC/CCC to advocate for access to rehabilitation services, and the importance of receiving support and champions to ensure rehabilitative needs of individuals living in LTC/CCC are being met. Access to recreation and leisure activities in LTC/CCC is also an important aspect of health and well-being.

Performance Measures +-

System indicators:

  1. Availability of active rehabilitation services for individuals with stroke living in long-term care settings.

Process indicators:

  1. Proportion of individuals with stroke who are discharged from acute care directly to a long-term care setting following an acute stroke.
  2. Proportion of readmissions to acute care for stroke-related causes following discharge to long-term care, stratified by type of stroke.
  3. Median wait time from referral to admission to nursing home, complex continuing care or long-term care facility.

Patient-oriented indicators:   

  1. Proportion of individuals with stroke who were living independently in a community setting prior to stroke who are admitted to long-term care following stroke.
  2. Changes in functional status from time of admission compared at 3 months, 6 months and one year following admission to long-term care.
  3. Number of visits to an emergency department within 3 months, 6 months and one year following admission to long-term care, stratified by reason for visit or hospital admission.
  4. Changes in quality of life measured at regular intervals during recovery and participation, and reassessed when changes in health status or other life events occur (e.g., at 60, 90- and 180-days following stroke).
  5. Onset of new pressure injury, falls or other complications related to stroke following discharge to long-term or complex continuing care within first year.
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

Following a stroke event, high levels of disability may warrant admission to a long-term care (LTC) institution. Independent predictors of discharge to a nursing home have been identified and include increasing age, increasing dependency for ADLs and absence of availability of a caregiver.46-50 The numbers of patients admitted to a long-term care facility, both immediately upon discharge from hospitals, and up to 10 years post stroke have been examined. Pooling the results from 18 studies, Burton et al.47 reported a median of 17% of patients were transferred directly to a LTC facility following discharge from an acute care hospital with a diagnosis of stroke. Between 10% and 11% of patients admitted to an acute care hospital were residing at an LTC facility at one, three- and 6-months following stroke.51 Brodaty et al.49 followed 202 participants, mean age of 72 years, without dementia who had suffered an ischemic stroke. Among those who survived, nursing home admission rates were 24% at 5 years and 32% at 10 years. Walsh et al.52 reported that among a group of 136 patients admitted to a stroke unit of a single hospital (median age was 77 years), 40.3% of patients were institutionalized at 4 years. 

Individuals with stroke discharged to long term care require discharge planning much like individuals returning to their own homes. Several studies have examined factors for effective discharge communication between inpatient hospital care and institutional care facilities. Clear communication between facilities regarding nutritional needs, functional status, communication abilities, risk assessment, and medical management is necessary for an optimal transition.53, 54

Individuals residing in skilled nursing facilities with staff trained in stroke management, and who have access to post stroke therapy resources, may experience better quality of life. In a study examining individuals living in a nursing home who received 24-hour care including access to psychiatric care, physician visits, daily physiotherapy, and weekly massage services, nursing home residents experienced greater quality of physical, psychological, social, and environmental quality of life scores compared with individuals living in their own homes receiving many of the same services.55 Individuals residing in nursing homes also experienced better perceived quality of life and health status than their residentially residing counterparts. However, the authors of a Cochrane review 56 stated there was insufficient evidence to support or refute the efficacy of occupational therapy (OT) interventions for improving, restoring or maintaining independence in ADL for stroke survivors residing in care homes. The OCTH trial 57 also examined the potential benefit of OT provided in long term care homes to residents with a history of stroke. 1,042 care home residents from 228 facilities, who were elderly (mean age 83 years) and with a high proportion who were severely disabled were randomized to an individualized program with a focus on improvement or maintenance of functional capacity, adaptations to the environment and included an education component for the care home staff, or to usual care. The median length of stay between care home admission and trial randomization was 2.2 years. The mean number of OT visits was 5.1 per participant. There was no significant difference in mean Barthel Index scores (primary outcome) between groups at 3, 6 or 12 months, or in any of the secondary outcomes. The authors concluded there was no evidence of benefit of the program.

Sex & Gender Considerations

In long-term care settings, sex and gender differences can potentially influence the course of recovery and the quality-of-care individuals with stroke receive, although research in this area is limited. Women, especially older women, tend to experience more severe and prolonged disabilities after stroke compared with men, and have increased frailty and comorbidities such as osteoporosis or other cardiovascular diseases. Women may also receive less aggressive rehabilitation in long-term care, as care plans often emphasize maintaining functional independence rather than aggressive recovery. Men often face more severe physical impairments early on and may struggle with stigma related to seeking emotional or psychological support, resulting in underreporting of depression or anxiety, conditions that can hinder rehabilitation progress. Men living in LTC settings may also experience lower quality-of-life compared with women.58

Stroke Resources
Previous Section 4. Outpatient & Community Based Rehabilitation, and Early Supported Discharge Next Section 6. Virtual Stroke Rehabilitation