Assessment for Rehabilitation: Pathway and Decision-Making Tool

1. Assessment for Rehabilitation: Pathway and Decision-Making Tool Susan Hillier on behalf of the ASC Rehabilitation Working Group and SA Stroke Network

2. Learning objectives This presentation will enable you to: • Recognise the importance of standardised rehabilitation assessment for people with stroke • Introduce the recommended rehabilitation pathway after stroke • Explain who should receive rehabilitation and the four exceptions

3. Learning objectives (cont) • Explain how to use the Rehab Assessment and Decision-Making Tool • Determine the appropriate rehabilitation setting using the Rehab Assessment and Decision-Making Tool • Determine the degree and nature of rehabilitation (domains) using the Rehab Assessment and Decision-Making Tool

4. Background • Currently only 41% of people with stroke are assessed for rehabilitation (NSF 2011) • Processes for Ax are highly variable and inconsistent between individual assessors (Kennedy, in press) • Ax is often based on non-clinical factors (Hakkennes 2011) or based on clinical factors that do not have a relationship with rehabilitation outcomes

5. Background (cont) • Ax is often not based on a person’s capacity to improve (Ilet 2010) • Assessment processes are poorly documented • All leading to the potential for ad hoc and potentially unfair decision making

6. Assessment for Rehabilitation: Pathway and Decision-Making Tool

7. Aims All stroke survivors in Australia should be assessed for rehabilitation This assessment should be: • Accountable, timely and transparent • Fair and consistent • Based on needs, not service availability, in the first instance • Include person, multidisciplinary team, family • Based on best available evidence

8. Who should receive rehabilitation? Stroke survivors may be rejected or never considered for rehabilitation due to: • Age • Rehab services not able to cater for severity or co-morbidities • Lived alone prior to stroke • Potential for long stay • Poor relationships between service providers • Deemed ‘not likely to benefit’

9. Who should receive rehabilitation? HOWEVER A systematic literature search failed to identify any clear indicators (clinical or otherwise) that could be used to determine ineligibility or unlikely to benefit from Rehab. It is therefore recommended that ALL STROKE SURVIVORS RECEIVE REHAB unless they meet one of the four exceptions.:

10. Exceptions to rehabilitation 1. Return to pre-morbid function: Stroke survivor has made a full recovery in all aspects including physical, emotional, psychological and cognitive. 2. Palliation: Death is imminent; refer to the palliative care team.

11. Exceptions to rehab (cont.) 3. Coma and/or unresponsive, not simply drowsy: Determined by criteria for minimally responsive, i.e. responds to stimuli meaningfully as able. 4. Declined rehabilitation: Stroke survivor does not wish to participate in rehabilitation. • If a stroke survivor meets any of these exceptions, regular monitoring is required to evaluate whether the exception is ongoing

13. Pathway (cont) Flags include: Premorbid conditions +/- ↓premorbid function Severe cognitive impairment High level medical/surgical acuity Non-compliance, apathy ↓social support/ accommodation options Double incontinence Somatoform disorders Co-morbidities (particularly those associated with ageing)

14. When, where and who uses the Rehab Decision-Making Tool Evidence suggests that rehabilitation should begin as early as possible (Bernhardt 2008) so assessment for rehabilitation should also be early. Pilot testing suggests commencing the process 48 hours after admission to help guide patient management. The Decision-Making Tool should be used in stroke units, but it can be used in other settings

15. When, where and who uses the Rehab Decision-Making Tool MDT members complete the sections relevant to their practice and/or The tool can be completed at a meeting with the MDT and the family or at ward rounds, formal or informal review meetings or within other local processes With familiarity takes about 10 minutes Can be updated as required during the hospital stay

18. Environment and participation documentation In order to provide a more complete picture of the stroke survivor and their rehabilitation needs there are two further tables (consistent with the WHO ICF model): Participation – this documents previous roles and need for rehabilitation Environment – documenting pre-stroke environment and flagging need for intervention if barriers identified

19. Example of participation section

20. Example of environment section

21. Summary Pathway - Consider exceptions to rehabilitation. If they do not apply proceed with decision making tool Decision making tool: • Domains – level of in/dependence plus • Need for rehabilitation and level • Where • Participation and environmental considerations

22. Implementation • We recommend a clear implementation process: • Raise awareness of pathway and tool generally in your institution • (Conduct audit of current practice) • Hold formal education session/s to become familiar with details and processes • Discuss implementation as a team • - Facilitators such as site champion • Barriers such as misunderstandings, time, resistance to documentation

23. Additional slides: • Working group members – ASC and SA Stroke Network • Methods for initial project • Pilot results • Modifications

24. ASC Rehabilitation working group: Overall mission: People with stroke should receive the right rehabilitation, at the right time, in the right place……….. Dr Geoff Boddice Dr Greg Bowring Ms Cindy Dilworth Dr David Dunbabin Dr Steven Faux Dr Howard Flavell Ms Megan Garnett Dr Erin Godecke Dr Kong Goh Dr Andrew Granger • Dr Susan Hillier (chair) • Dr Genevieve Kennedy • Ms Sandra Lever • Dr Natasha Lannin • Mr Bill McNamara • Ms Jill McNamara • Ms Juvy McPhee • Mr Chris Price • Ms Frances Simmonds • Ms Leah Wright

25. SA Network Rehabilitation working group: Susan Hillier (Chair), Jodie Aberle, Peter Anastassiadis, Kelli Baker, Elizabeth Barnard, Matt Barrett, Gillian Bartley, Peter Bastian, Maryann Blumbergs, Maree Braithwaite, Jordie Caulfield, Amanda Clayton, Denise Collopy, Maria Crotty, Michelle Curtis, Robyn Dangerfield, Grant Edwards, John Forward, Caroline Fryer, Kendall Goldsmith, Carole Hampton, Peter Hallett, Robyn Handreck, Tony Hewitt, Patricia Holtze, Theresa Hudson, Venugopal Kochiyil, Catherine Lieu, Shelley Lush, Elizabeth Lynch, Annette McGrath, Antonia McGrath, James McLoughlin, Jo Murray, Lee O’Brien, Debra Ormerod, Elizabeth Sloggett, Sally Sobels, Yvonne Tiller, Roly Vinci, Anne Walter, Lauri Wild, Brad Williams, Cathy Young.

26. Aim: to devise a process for assessing people for stroke rehabilitation, that is clear, consistent and based on need in the first instance. Method: 52 sites 104 articles * Funding from Bayer Australia 40 great minds

27. Piloting – in sites in most states (n=6) Positives: ensured clear and accountable decision-making, focused on the person with stroke and their family (not services) Increased involvement of all stroke team members More wholistic as based on the ICF-WHO framework.

28. Piloting – in sites in most states (n=6) • Negatives: • Already do it • Haven’t got time • No outcome measures • Unrealistic because some people don’t improve with rehabilitation

29. Changes and additions Wording Recommend commences in first 48 hrs – at minimum within first week Done at team meetings with family if at all possible and updated similarly Can be championed by one person but needs whole team input Use as handover between services

30. Changes and additions Initially time consuming but with practice can be 10 mins Format that can be adapted to suit local record keeping Maintain integrity of intention Useful for stroke survivor/family ? as held record Stress this is survivor-centred and services may not exist to match identified need (YET)

31. For further information about the Rehabilitation Assessment and Decision-making tool please contact either: Susan Hillier – susan.hillier@unisa.edu.au or Leah Wright – lwright@strokefoundation.com.au