1. Stroke Reference GroupRecommendations for Stroke Rehabilitation Presentation to the Rehab/CCC Expert Panel March 24,2011

2. Presentation Overview • Proposed Evidence Based Best Practice Standards/Metrics • Considerations • Phase 1 Action Items • Discussion

3. “Time is Function” • Brain is “primed” to “recover” early post-stroke • Delays in starting rehab are detrimental to recovery (Biernaskie et al., 2004). • Day 5 admission = marked improvement • Day 14 admission = moderate improvement • Day 30 admission = no improvement vs. controls

4. Emergency Care • Best Practice Standard: • Emergency Department Evaluation and Management of Patients with TIA and Ischemic Stroke • Acute Thrombolytic Therapy • Acute Stroke Paramedic Prompt Card Protocol • Minimize LOS • Proposed Metrics: • LOS • For all pts admitted to stroke unit • CT Scan within 24 hours of admission

5. Acute Care and Rehabilitation in the Acute Phase • Standard: • Patients admitted to hospital because of an acute stroke or transient ischemic attack should be treated on an interprofessional stroke unit [Evidence Level A]. • Alpha FIM completed on Day 3 • Discharge planning • Mobilization within 24 hours of admission • Prevention and management of Complications Following Acute Stroke • Metrics: • % admitted to stroke unit • Onset to rehab: • Ischemic Strokes- Day 5 • Hemorrhagic strokes-Day 7 • Alpha FIM completed Day 3 • % of pts with ALC days • All cause readmission rates • % of pts with Alpha FIM categories who were d/c to planned rehab destination • % d/c to inpatient rehab

6. Inpatient Rehabilitation • Standard: • Stroke Rehabilitation Unit • Minimum of 3 hours of direct individualized therapy per day • 7 day/week service • 7 day/week admission process • Rehabilitation ALC has priority access to LTC • Metrics: • Provincial workload definition of direct minutes of therapy per day( therapist vs assistant) • Discharge destination • ALC LOS • ALC rates per X patients • All cause readmission rates • FIM efficiency by RPG NB: For Every 13 patients treated in a stroke rehab unit, 1 patient is saved from death or dependence

7. Ambulatory Rehabilitation/Community Care • Best Practice Standard: • Ambulatory rehab model (CCAC, community based, hospital based) • Decrease admission of mild strokes through increased access to early outpatient rehab for those with high early FIM • Access to enhanced attendant care/supports in early discharge phase for ALC pts • Outpt or enhanced CCAC therapy visits: 2-3 visits/week for 12 weeks • Metrics: • CCAC referral date • Time to first CCAC visit • FIM Efficiency • Readmission rate

8. Therapy is Cheap; LOS is Not Outpatient therapy improves short-term functional outcomes It is relatively inexpensive (1 PT/1 OT/0.5 SLP/0.5 SW = cost of 1 inpatient rehab bed) Reduces re-hospitalization and allows earlier discharge home Estimated savings is $2 for every $1 spent on outpatient therapies Only 3% of stroke rehab referrals from acute care were sent to day hospital / ambulatory care* *E-Stroke data 2009/2010

9. Is it possible/ Current initiatives? • High variability seen across the province as far as onset days to rehab- a number of centres are doing quite well and even some freestanding centers e.g. St Johns Rehab 7 day admission & service • Toronto Central LHIN clinical efficiency task group endorsed- detailed work to look at both streamlining Acute and Rehab care • Pilot studies of enhanced outpatients have shown expected benefits ( Southwest and South east Ontario)

10. What is the Critical Mass?

11. Action Items to Accelerate Best Practices and Impact ALC • Early Access: • Mobilization within 24 hours of admission • Alpha FIM completed on Day 3 • Alpha FIM score > 80 = outpt rehabilitation • Alpha FIM score 40-80= inpatient rehabilitation • Alpha FIM score 40-60= ? Inpatient rehabilitation • Alpha FIM score <40= options for restorative/ongoing assessment • Onset to Rehab: • Ischemic strokes= Day 5 • Hemorrhagic strokes= Day 7 • Rehabilitation has same priority level as acute care for access to LTC

12. Action Items to Accelerate Best Practices and Impact ALC • Intensification: • 7 day a week admission process • 7 day a week service • Minimum 3 hours direct therapy per day • Appropriate Settings: • Acute and Rehabilitation Stroke Units • Ambulatory and Community Rehabilitation • Performance Management/Benchmarking: • Establish accountabilities based on targets/metrics • Support inclusion of Alpha FIM in CIHI DAD • Define workload measurement system provincially • Establish Ambulatory care database

13. Discussion