Are Stroke Survivors Discharged to the Recommended Postacute Setting?

A Comparison of Acute Ischemic Stroke Patients Discharged to Inpatient Rehabilitation vs a Skilled Nursing Facility: The Paul Coverdell National Acute Stroke Program

OBJECTIVE

To compare the sociodemographic, clinical, and hospital related factors associated with discharge of acute ischemic stroke (AIS) survivors to inpatient rehabilitation (IRF) and skilled nursing facility (SNF) rehabilitation services.

DESIGN

Retrospective descriptive study from the Paul Coverdell National Acute Stroke Program (PCNASP) participating hospitals during 2016 to 2019.

SETTING

9 Participating states from PCNASP in United States.

PARTICIPANTS

130,988 patients with AIS from 569 hospitals (N=337,857).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Discharge to IRF and SNF.

RESULTS

Patients discharged to a SNF had longer length of hospital stay, more comorbidities, and higher modified Rankin scores compared with patients discharged to an IRF. Nine characteristics were associated with being less likely to be discharged to an IRF than an SNF: older age (85+ years old, adjusted odds ratio [AOR]=0.20 [confidence interval [CI]=0.18-0.21]), identifying as non-Hispanic Black (AOR=0.85 [CI=0.81-0.89]), identifying as Hispanic (AOR=0.80 [CI=0.74-0.87]), having Medicaid or Medicare (AOR=0.73 [CI=0.70-0.77]), being able to ambulate with assistance from another person (AOR=0.93 [CI=0.89-0.97]), being unable to ambulate (AOR=0.73 [CI=0.62-0.87]) and having comorbidities, prior stroke (AOR=0.69 [CI=0.66-0.73]), diabetes (AOR=0.85 [CI=0.82-0.88]), and myocardial infraction or coronary artery disease (AOR=0.94 [CI=0.90-0.97]). Four characteristics were associated with being more likely to be discharged to an IRF than an SNF: being a man (AOR=1.20 [CI=1.16-1.24]), and having a slight disability (Rankin Score 2) (AOR=1.41 [CI=1.29-1.54]), being at larger hospitals (200-399 beds: AOR=1.31 [CI=1.23-1.40]; 400+ beds: AOR=1.29 [CI=1.20-1.38]), and being at a hospital with stroke unit (AOR=1.12 [CI=1.07-1.17]).

CONCLUSION

This study found differences in demographic, clinical, and hospital characteristics of AIS patients discharged for rehabilitation to an IRF vs SNF. The characteristics of patients receiving rehabilitation services may be helpful for researchers and hospitals making policies related to stroke discharge and practices that optimize patient outcomes. Populations experiencing inequities in access to rehabilitation services should be identified, and those who qualify for rehabilitation in IRF should receive this care in preference to rehabilitation in SNF.

Utility of the AM-PAC "6 Clicks" Basic Mobility and Daily Activity Short Forms to Determine Discharge Destination in an Acute Stroke Population

IMPORTANCE

The American Heart Association and American Stroke Association recommend early identification of level of rehabilitative care as a priority after stroke.

OBJECTIVE

To evaluate the utility of the Activity Measure for Post-Acute Care (AM-PAC) "6 Clicks" Daily Activity and Basic Mobility forms to determine the next level of rehabilitation after hospitalization for adults with stroke.

DESIGN

Retrospective cohort design using medical records from 2015 to 2016.

SETTING

Major urban hospital.

PARTICIPANTS

Patients admitted to the stroke service, with a confirmed stroke, who were seen by a physical or occupational therapist; who had a 6 Clicks Basic Mobility or Daily Activity score at initial evaluation; and who were discharged to home, an acute inpatient rehabilitation facility (IRF), or a subacute skilled nursing facility (SNF).

OUTCOMES AND MEASURES

Length of stay and discharge destination.

RESULTS

Seven hundred four participants (M age = 68.28 yr; 51.21% female) were included. Analysis of variance and receiver operating characteristic curves were performed. Daily Activity scores were highest for home discharge, lower for IRF discharge, and lowest for SNF discharge; Basic Mobility showed a similar pattern. Cutoff values distinguishing home from further inpatient rehabilitation were 44.50 for Basic Mobility and 39.40 for Daily Activity scores (area under the curve [AUC] = .82 for both forms), with scores of 34.59 (AUC = 0.64) and 31.32 (AUC = 0.67) separating IRF from SNF, respectively.

CONCLUSIONS AND RELEVANCE

Therapists should incorporate 6 Clicks scores into their discharge planning. What This Article Adds: This research demonstrates the utility of an outcome measure in the acute care setting that assists in planning discharge destination for patients with stroke.

Which Road to Recovery?: Factors Influencing Postacute Stroke Discharge Destinations: A Delphi Study

BACKGROUND AND PURPOSE

The criteria for determining the level of postacute care for patients with stroke are variable and inconsistent. The purpose of this study was to identify key factors influencing the selection of postacute level of care for these patients.

METHODS

We used a collaborative 4-round Delphi process to achieve a refined list of factors influencing postacute level of care selection. Our Delphi panel of experts consisted of 32 panelists including physicians, physical therapists, occupational therapists, speech-language pathologists, nurses, stroke survivors, administrators, policy experts, and individuals associated with third-party insurance companies.

RESULTS

In round 1, 207 factors were proposed, with subsequent discussion resulting in consolidation into 15 factors for consideration. In round 2, 15 factors were ranked with consensus on 10 factors; in round 3,10 factors were ranked with consensus on 9 factors. In round 4, the final round, 9 factors were rated with Likert scores ranging from 5 (most important) to 1(not important). The percentage of panelists who provided a rating of 4 or above were as follows: likelihood to benefit from an active rehabilitation program (97%), need for clinicians with specialized rehabilitation skills (94%), need for active and ongoing medical management and monitoring (84%), ability to tolerate an active rehabilitation program (74%), need for caregiver training to return to the community (48%), family/caregiver support (39%), likelihood to return to community/home (39%), ability to return to physical home environment (32%), and premorbid dementia (16%).

CONCLUSIONS

This study provides an expert, consensus-based set of key factors to be considered when determining where stroke patients are discharged for postacute care. These factors may be useful in developing a decision support tool for use in clinical settings.