Presentation for NEO Clinicians on the Stroke Rehabilitation

							  Consensus Panel on the
Stroke Rehabilitation System
         “Time is Function”

Jenn Fearn, Regional Rehabilitation Coordinator
 Darren Jermyn, Regional Program Manager
    Northeastern Ontario Stroke Network
                                       December 11, 2007
              Take Home Points
• What is the Final Report of the Stroke
  Rehabilitation System Consensus Panel, 2007?

• What are some of the key highlights of the report?

• Where/Who can I go to for further information on
  Outcome Measures and Stroke Rehabilitation
  Information?

• What is the North Eastern Ontario Rehabilitation
  Network (NEORN)?
         Impact and Cost of Stroke
• Stroke is a leading cause of death and disability
  with high health care and human costs
  ($2.7 billion annual cost to Canadian economy)

• In Ontario – 24,000 patients present yearly to
  hospitals with signs and symptoms of stroke and
  there are at least 90,000 Ontarians living with the
  effects of stroke

• In 2005-06 there were 1124 hospital admissions
  for stroke or stroke related diagnosis in the North
  East LHIN (CIHI-NACRS data – SEAC Report 2006)
      Recent Advancements in Stroke
         Rehabilitation Initiatives
• The release of HSFO’s Best Practice Guidelines for Stroke Care
  (transition management, rehabilitation management and
  community re-engagement) (2003)
• Evidence-Based Review of Stroke Rehabilitation (EBSRB)
  Dr. R. Teasell – London, ON (2003 to present)
• Recommendations from the 6 stroke rehabilitation pilot projects
  (2004)
• Documentation of new evidence on the efficacy and cost-
  effectiveness of stroke rehabilitation (ongoing)
• The approval and funding of the Community and LTC Specialist
  (2004) and the Rehabilitation Coordinator (2005) positions
  across the stroke regions
• Canadian Stroke Strategy – Best Practice Recommendations
  (2006)
Specifically, the Panel was formed to:
• Describe and define the components of the
  Stroke Rehabilitation System in Ontario
• Identify components of a Service Provision
  Model (triage system)
• Develop stroke rehabilitation Standards
• Select the common assessment tools
• Take initial steps in the development of a
  province-wide data system for stroke
  rehabilitation
• Make Recommendations to move the stroke
  rehabilitation agenda forward
   Vision for Stroke Rehabilitation
              in Ontario
• Individuals who experience a stroke will
  have timely access to the appropriate
  intensity and duration of rehabilitation
  services.
• These services will be provided in a
  comprehensive and coordinated way to
  patients and families, by agencies and
  health care providers who are expert in
  stroke care and practice rehabilitation
  principles.
     Definition of „Rehab Ready‟

The Panel defined 5 criteria for determining
whether a stroke survivor is ready to begin
rehabilitation outside the acute care setting,
they are:
   1. Readiness for D/C from acute care,
   2. Medical stability,
   3. Ability to learn,
   4. Ability to participate, and
   5. Consent.
Categories of the Severity of Stroke

                             Severity of the Stroke
                         Severe Moderate        Mild
Early FIMTM Score*
     Total FIMTM             < 40    40 - 80   > 80
   Motor Function            < 38    38 - 62   > 62
*(5 to 7 days post stroke)
Service Provision Model
Service Provision Model
              • A Rehab “Triage Tool”
              that applies across the
              entire care continuum

              • A starting algorithm that
              provides the foundation
              for a standardized
              approach for regional
              triage systems across
              each stroke region in the
              province

              • It is expected that each
              stroke region will adapt
              the model and develop
              more detail in the process
              as appropriate
Moderate Stroke
                             Moderate Stroke
Screen/Assess The stroke survivor requires an acute admission and is deemed Rehab Ready.
Define             Based on the outcome of the assessment, the rehab professional determines
                   that the stroke survivor meets the criteria for inpatient rehab.

Refer/Transfer     The rehab professional then refers the stroke survivor to a stroke rehab unit.

Screen/Assess The stroke survivor is reassessed at the end of the formal rehab program, and
                   it is determined that the stroke survivor would benefit from additional rehab.

Define             Based on the outcome of the assessment, the rehab professional determines
                   that the stroke survivor meets the criteria for home-based stroke rehab
                   services.

Refer/Transfer     The stroke survivor is discharged home and referred to home-based services
                   for rehab and other support services.

Screen/Assess At the end of the home-based rehab program, the stroke survivor is
                   reassessed and no further rehab needs are identified.

Screen/Assess The stroke survivor is reassessed periodically, but no further rehab needs are
                   identified.
Standards
  Standards for Stroke Rehabilitation
Overarching Principles
  1. Stroke survivors will have timely, equitable and
     consistent access to coordinated rehabilitation
     services.
  2. Rehabilitation at all points along the care
     continuum will be evidence based where
     evidence is available and be provided by
     appropriate rehabilitation professionals and
     other health care providers with expertise in
     stroke rehabilitation.
  3. An interprofessional model of care will be used
     when assessing and treating all stroke
     survivors.
       Classifying the Standards

4 Main Areas
  – Education
  – Best Practice Stroke Care
  – System Navigation
  – Regional System of Care
                                }
                                }
                                    Clinicians
                                    Management/
                                    System Level
Specific Standards of Interest to
         NEO Clinicians
           Standards - Education
Standard #5:
  Stroke related impairments and functional
  status will be evaluated by rehabilitation
  professionals trained in stroke rehabilitation
  using standardized, valid assessments.

Recent Project to Achieve Standard:
 Two workshops were offered in Sudbury on
 October 27 & 28, 2007 for occupational therapists
 and physiotherapists on the following
 recommended assessments:
    • Chedoke-McMaster Stroke Assessment
    • Chedoke Arm and Hand Activity Inventory
National Expert Consensus
    Panel for Outcome
Measurements Post-Stroke
 Canadian Best Practices in Stroke
     Rehabilitation Outcomes
Conference
 Held February 6-7, 2006
Goals: Through discussion with Canadian Stroke
 Network and the Heart and Stroke Foundation of
 Ontario, it was agreed that an expert
 consensus panel with representatives from
 relevant health professionals as well as
 stakeholders would be an important method for
 establishing a course of rehabilitation
 outcome measures to be used across the
 continuum.
 Canadian Best Practices in Stroke
     Rehabilitation Outcomes
Conference Chairs
  Dr. Mark Bayley, Dr. Patrice Lindsay
Membership
 Dr. Nicol Korner-Bitensky,
 Dr. Robert Teasell,
 Dr. Johanne Desrosiers,
 Dr. Jeff Jutai,
 Alison MacDonald,
 Katherine Salter,
 Dr. Sharon Wood-Dauphinee,
 Nancy Deming.
  Canadian Best Practices in Stroke
      Rehabilitation Outcomes
Objectives
1. Using the International Classification of
   Functioning to prioritize a set of outcome
   measures in the domains of body structure
   and function, activity and participation that
   could be used to evaluate the outcome of
   stroke rehabilitation in Canada.
2. Identify preliminary indicators of performance
   of the stroke rehabilitation system.
  Canadian Best Practices in Stroke
      Rehabilitation Outcomes
Criteria Suggested to Facilitate Selection:
• The measure should have been used in
  previous stroke trials as identified by the Stroke
  Rehabilitation Evidence-Based Review.

• The measure can be used at admission and
  completion of rehabilitation.

• The measure can be administered in a
  multidisciplinary fashion – i.e., could be
  administered by a number of different health
  professionals.
   Canadian Best Practices in Stroke
       Rehabilitation Outcomes
• The measure should have optimal psychometric
  properties including reasonable reliability and
  demonstrated validity.
• The measure should be available in English and
  French.
• The time required to complete the measure should fit
  within the context of the usual assessment time of a
  health care professional (i.e., is not excessively
  burdensome).
All Measures Selected Also Considered:
• Ease and feasibility of administration; Content of the
  measure; Reliability, Validity and Responsiveness.
Appendix M: Outcome Measures
   Canadian Best Practices in Stroke
       Rehabilitation Outcomes
 The Domains
• Measures of Stroke       • Cognition
  Severity                 • Arm Function
• Medical Co-morbidities   • Walking/Lower Extremity
• Upper Extremity          • Balance
  Structure and Function   • Functional Communication
• Lower Extremity          • Self-Care Activities of Daily
• Spasticity                 Living
• Visual Perception        • Instrumental Activities of
• Language                   Daily Living
• Speech Intelligibility   • Participation
  Tool
Outcome Measures Resource List
           Standards - Education
Standard #12a:
 The interprofessional team will have access to
 stroke rehabilitation education and professional
 development modules in order to support the
 standards and other evidence-based practice
 initiatives.
 These educational opportunities will be evidence-
 based, current and user-friendly and will
 incorporate knowledge translation strategies.

Resources:
 Stroke Rehabilitation Resource Guide available at:
 http://profed.heartandstroke.ca/
 (Ontario Stroke System - Stroke - Professional
 Resources - Stroke Rehabilitation Resource Guide)
Stroke Rehabilitation Resource Guide
• Ambulation/Mobility       • Pain
• Aphasia & Other           • Pediatric Stroke
  Communication
  Impairments               • Pusher Syndrome
• Assessment & Outcome      • Recreation
  Measures
                            • Rehabilitation
• Cognitive, Perceptual &
  Behavioural Problems      • Sexuality
• Community                 • Survivor & Caregiver
  Re-engagement               Support & Education
• Continence
                            • Transition Management
• Depression & Mood
                            • Upper Extremity
• Driving
• Dysphagia and Nutrition   • Web Resources
            Standards - Education
Standard #12b:
 Stroke survivors, family/caregivers and
 volunteers should be provided with information
 and education at all stages of care across the
 continuum (prevention, acute care, rehabilitation,
 community reintegration).
 It should address: the nature of stroke and its
 manifestations, signs and symptoms, impairments
 and their impact and management, risk factors,
 planning and decision making, resources and
 community support.
Possible Projects or Initiatives:
 Inpatient and family education programs, Living with
 Stroke, Moving on After Stroke (MOST), Stroke
 Survivor Canada
             Standards - Education
Standard #6:
  The interprofessional team will develop a
  comprehensive rehabilitation plan with each stroke
  survivor that reflects the severity of the stroke, the
  needs and goals of the stroke survivor, and the
  family/caregiver and home environment.

Possible Projects or Initiatives:
  Explore the feasibility of the potential use of the
  NEO Video Stroke Network to assist small hospitals
  with treatment advice/options or to discuss
  complicated cases.
Standards – Best Practice Stroke Care
Standard #11:
Therapy will include repetitive and intense use of
novel tasks that challenge the stroke survivor to
acquire necessary skills during functional tasks
and activities.
The interprofessional team, along with the
family/caregiver and volunteers, will promote the
practice of skills gained in therapy into the stroke
survivor’s daily routine and will reinforce increased
stroke survivor participation and activity.
Possible Projects or Initiatives:
Workshops, Inservices, Rounds with respect to
‘novel tasks’
Standards – Best Practice Stroke Care
Standard #16:
  Stroke survivors who are discharged to the
  community with home-based stroke rehabilitation
  services will be provided with these services as
  per available evidence-based guidelines.

Current Projects or Initiatives:
  • Stats are being collected from all 6 branches of
    the NE CCAC including West Parry Sound. The
    data is being compared to the Community and
    Stroke Best Practice Guidelines (2005)
  • In future, target CCAC case managers with
    further education.
      Standards – System Navigation
Standard #17:
 Interprofessional teams will facilitate linkages for
 stroke survivors and their family/caregivers after
 discharge to services in the community.
Current Projects or Initiatives:
 Stroke Community Resource Guides
  Developed in each district outlining stroke and/or
  stroke related services available in the community
  (e.g. CCAC contact info, Driving Eval. info, Rehab Services, etc.)

 Collaborative Workshops offered across NEO
  Involve the partnership between the Psychogeriatric Resource
  Consultants, the Regional Best Practice Coordinator for LTC and
  the NEO Stroke Network Community and Long-Term Care
  Specialist. These workshops provide an opportunity to network,
  learn more about community resources and how to combine
  various initiatives to address the needs of clients.
Selected Management/System Level
    Standards the NEO Clinician
        Should Be Aware Of
  Selected Management/System Level
              Standards
Standard #13:
  All stroke survivors, regardless of where they live,
  will have equitable access to the same standard of
  care at the appropriate intensity and duration.
Standard #19:
  Each stroke region will have an explicit stroke
  rehabilitation service provision model in place in
  order to facilitate optimal and timely access to
  rehabilitation services.
Standard #20:
  Clinical and service utilization data will be used to
  plan, coordinate, integrate and prioritize regional
  stroke rehabilitation services and ensure equitable
  access based on patient need.
      Evaluation of the Standards
As the stroke rehabilitation community begins
to implement the standards proposed in this
report, health care providers, administrators
and funders will need to:
  • Understand how well the system (or region) is
     performing against the established standards.
  • Analyze what has changed for stroke survivors,
     in both qualitative and quantitative terms, once
     the standards have been implemented.
  • Determine whether stroke survivors were able
     to access the recommended services, which
     services were accessed, and what barriers to
     access still exist within and across regions and
     LHINs.
 Recommended Next Steps To Move
 The Rehabilitation Agenda Forward
Adopt the Standards
        •   (3 Recommendations)
Create Needed Capacity to Deliver Stroke Rehab
        •   (2 Recommendations)
Develop Regional Systems
        •   (3 Recommendations)
Take Action to Relieve the Human Resource Shortage
        •   (1 Recommendation)
Facilitate Evaluation and Research
        •   (2 Recommendations)
   Development of Regional Systems
           Recommended Next Steps
  That each Stroke Region work in conjunction with its
  respective Local Health Integration Network in:

• Developing and implementing a plan based on the
  Panel’s standards in order to meet the service needs
  of stroke survivors in their area (Recommendation 6)
• Developing a process for referral to the appropriate
  services and tracking where and when the
  appropriate service does not occur (Recommendation 7)
• Developing stroke rehabilitation service capacity to
  meet the Panel’s standards and in facilitating
  interorganizational agreements that support having
  the right person in the right place at the right time
  (Recommendation 8)
North Eastern Ontario
Rehabilitation Network



         Established: November 2006
                              NE LTC
                              Homes,                        Link with other
                            Community &                     established
              NE                                            Networks – i.e.
                            Mental Health      NE
           Hospitals                                        Dementia, ABI, &
                             Agencies       Community
          with Rehab                                        other Regional
                                             Hospitals
             Beds                                           Rehab Networks)

                         North Eastern
                                                     Ontario
   North East              Ontario                Telemedicine
    CCAC
                         Rehabilitation             Network

                           Network
           Regional
          Networks:                           Academic
          Stroke, ABI                        Institutions
                             North East
                               LHIN



              Proposed
Current
               Future
Members
              Members
      Work Accomplished to Date
Information sharing
 • Admission criteria for designated rehabilitation
   beds
 • Utilization data related to admission and D/C
   data
 • Compiling resource inventory (e.g. inpatient,
   outpatient, day-hospital services and FTE’s
   associated with these services)
 • Sharing educational information
Developed Terms of Reference
 • Draft Vision, Purpose, Objectives, Accountability
   and Responsibility, etc.
       Meeting with the NE LHIN
Oct 1, 2007, 3 members of the NEO Stroke
Network met with the NE LHIN senior
management team
   • Case was made for more rehabilitation beds
   • Proposed the concept of a regional
     rehabilitation database (electronic tracking
     record)
   • NEO Rehabilitation Network was explained
     and we asked for the NE LHIN’s
     endorsement of the NEORN workplan
North Eastern Ontario Rehabilitation Network
                 Workplan
•   Create an established link with the NE LHIN – to develop capability to
    advise on rehabilitation practice, policy and funding
•   Establish linkages/communication between acute care, inpatient
    rehab beds, and community-based rehabilitation providers in NEO
•   Common referral form for rehabilitation across all NEO Rehab Beds –
    this will lead to the use of a common language and common assessment
    information
•   Develop transparent guidelines for rehabilitation referral process (that
    address geography and patients with special needs) and repatriation
    agreements between organizations
•   Use of telemedicine for consultation/assessment and educational
    opportunities
•   Development and sustainability of a NE Rehabilitation Resource
    Directory
•   Improved dissemination of rehabilitation best practices through a
    coordinated regional rehabilitation education system/function
           Some Useful Links
StrokEngine
http://www.medicine.mcgill.ca/Strokengine/

Evidence-Based Review Of Stroke Rehabilitation
(EBRSR)
http://www.ebrsr.com/

Heart and Stroke Foundation of Ontario
(HSFO) (Prof. Ed. Section under revision at present)
http://profed.heartandstroke.ca/

Northeastern Ontario Stroke Network Website
www.neostrokestrategy.com
 NEO Regional Stroke Best Practice
Consultant Team & Discussion Forum




    www.neostrokestrategy.com
        Contact Info
          Jenn Fearn
 Regional Rehabilitation Coordinator
    jfearn@hrsrh.on.ca

        Darren Jermyn
    Regional Program Manager
   djermyn@hrsrh.on.ca

www.neostrokestrategy.com