4. Outpatient and In-Home Stroke Rehabilitation (including Early Supported Discharge)
6th Edition - 2019 UPDATED
4.1 Outpatient & In-Home Rehabilitation
- Following stroke, people with ongoing rehabilitation goals should continue to have access to specialized stroke services after leaving hospital [Evidence Level A].
- This should include facility-based outpatient services and/or in-home rehabilitation services [Evidence Level A].
- Outpatient and/or in-home rehabilitation services should be provided by specialized interdisciplinary team members as appropriate to patient needs and in consultation with the patient and family [Evidence Level C].
- Services should ideally begin within 48 hours of discharge from an acute hospital or within 72 hours of discharge from inpatient rehabilitation [Evidence Level C].
- The choice of setting for outpatient and/or in-home rehabilitation service delivery should be based on patient functional rehabilitation needs, participation-related goals, availability of family/social support, patient and family preferences [Evidence Level C].
- Patients and families should be involved in their management, goal setting, and transition planning [Evidence Level A].
- Outpatient and/or in-home rehabilitation services should include the same elements as coordinated inpatient rehabilitation services [Evidence Level B], and include:
- An interdisciplinary stroke rehabilitation team [Evidence Level A].
- A case coordination approach including regular team communication to discuss assessment of new clients, review client management, goals, and plans for discharge or transition [Evidence Level B].
- Therapy provided for a minimum of 45 minutes per day [Evidence Level B] per required discipline, 2 to 5 days per week, based on individual patient needs and goals [Evidence Level A]; ideally for at least 8 weeks [Evidence Level C].
- Interprofessional care planning and communication is essential to ensure continuity of care, patient safety, and to reduce risk of complications and adverse events during stroke care particularly at transition points. [Evidence Level C]. Refer to Transitions and Community Participation Module, Section 3 for more information.
- At any point in their recovery, people 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 outpatient rehabilitation if they meet the requirements outlined in Box One: Eligibility and Criteria for Stroke Rehabilitation [Evidence Level B].
4.2 Early Supported Discharge (ESD)
- Early supported discharge services, designed to reduce length of hospital stay and still provide same intensity of inpatient rehabilitation, are an acceptable form of rehabilitation and should be offered to a select group of patients when available and provided by a well-resourced, coordinated specialized team [Evidence Level A].
- Criteria for ESD candidacy include:
- Mild to moderate disability [Evidence Level A];
- Ability to participate in rehabilitation from the point of discharge [Evidence Level A];
- Medically stable, availability of appropriate nursing care, necessary resources and support services (e.g., family, caregivers, and home care services) [Evidence Level A].
- ESD services should be provided within 48 hours of discharge from an acute hospital or within 72 hours of discharge from inpatient rehabilitation [Evidence Level C].
- 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 patient needs [Evidence Level B]. Refer to Section 3 for more information.
- Where possible, it should be provided by the same team that provided inpatient rehabilitation to ensure smooth transition [Evidence Level A]
- Where different therapists are providing the home-based rehabilitation, close communication with the hospital-based rehabilitation team is important during the transition and processes to facilitate communication should be implemented [Evidence Level C].
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 exist 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 and participation takes up to one-year or more post-stroke and individuals make the most gains within the first 6 months post-stroke.
When physical limitations are minor, people with stroke emphasize the need to still receive psychological support and care. In addition, people with stroke state that education is required to ensure expectations for recovery are understood and that the steps for how to re-access rehabilitation services are clear. A stroke navigator or similar role has been recognized as an effective model during this stage to help link people with stroke to the appropriate local services or telehealth services, including accessing transportation assistance if required. Furthermore, post discharge from inpatient rehabilitation, people with stroke emphasized the importance of education relating to available support groups, including local groups and groups via telehealth or social media.
There is a marked lack of available outpatient and community-based rehabilitation resources. Therefore, the health system should aim to provide the following:
- 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).
- Median length of time between referral for outpatient rehabilitation to admission to a community rehabilitation program.
- Frequency and duration of services provided by rehabilitation professionals in the community.
- Magnitude of change in functional status scores, using a standardized measurement tool, for stroke survivors engaged in community rehabilitation programs.
- Length of time between referral for ongoing outpatient/community rehabilitation to commencement of therapy.
- 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.
- 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).
- Number of stroke patients assessed by physiotherapy, occupational therapy, speech–language pathologists and social workers in the community.
- Use of health services related to stroke care provided in the community for stroke rehabilitation, including timing and dose of services.
- 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
Health Care Provider Information
- FIM® Instrument
- AlphaFIM® Instrument
- Chedoke-McMaster Stroke Assessment Scale
- Evidence-Based Review of Stroke Rehabilitation (Triage Module)
- Reintegration to Normal Living Index
- Leisure section of the Assessment if Life Habits (LIFE-H)
- Stroke Impact Scale
- Stroke Engine
Information for People with Stroke, their Families and Caregivers
- Taking charge of your stroke recovery: Rehabilitation and recovery infographic
- Taking charge of your stroke recovery: Transitions and community participation infographic
- Aphasia Institute
- Post Stroke Checklist
- Stroke Resources Directory
- Your Stroke Journey
- Stroke Engine
- Heart and Stroke Foundation Canadian Partnership for Stroke Recovery
- Taking charge of your stroke recovery: 2020 Virtual healthcare checklist infographic
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.