Impact of Medicare's Prospective Payment System for Inpatient Rehabilitation Facilities on Stroke Patient Outcomes

Suggesting global insights to local challenges: expanding financing of rehabilitation services in low and middle-income countries

Purpose

Following the rapid transition to non-communicable diseases, increases in injury, and subsequent disability, the world-especially low and middle-income countries (LMICs)-remains ill-equipped for increased demand for rehabilitative services and assistive technology. This scoping review explores rehabilitation financing models used throughout the world and identifies "state of the art" rehabilitation financing strategies to identify opportunities and challenges to expand financing of rehabilitation.

Material and methods

We searched peer-reviewed and grey literature for articles containing information on rehabilitation financing in both LMICs and high-income countries.

Results

Forty-two articles were included, highlighting various rehabilitation financing mechanism which involves user fees and other innovative payment as bundled or pooled schemes. Few studies explore policy options to increase investment in the supply of services.

Conclusion

this paper highlights opportunities to expand rehabilitation services, namely through promotion of private investment, improvement in provider reimbursement mechanism as well as expanding educational grants to bolster labor supply incentive, and the investment in public and private insurance schemes. Mechanisms of reimbursement are frequently based on global budget and salary which are helpful to control cost escalation but represent important barriers to expand supply and quality of services.

Home-Based Transcranial Direct Current Stimulation to Enhance Cognition in Stroke: Randomized Controlled Trial

BACKGROUND

Transcranial direct current stimulation (tDCS) is a promising tool for improving post-stroke cognitive function. Home-based rehabilitation is increasingly required for patients with stroke, and additional benefits are expected if supplemented with remotely supervised tDCS (RS-tDCS). We evaluated the cognitive improvement effect and feasibility of RS-tDCS in patients with chronic stroke.

METHODS

Twenty-six patients with chronic stroke and cognitive impairment (Korean version of the Montreal Cognitive Assessment [K-MoCA] score <26) were randomized into real and sham RS-tDCS groups and underwent concurrent computerized cognitive training and RS-tDCS. Patients and caregivers underwent training to ensure correct tDCS self-application, were monitored, and treated 5 d/wk for 4 weeks. We investigated several cognition tests including K-MoCA, Korean version of the Dementia Rating Scale-2, Korean-Boston Naming Test, Trail Making Test, Go/No Go, and Controlled Oral Word Association Test at the end of the training sessions and one month later. Repeated-measures ANOVA was used for comparison between the groups and within each group. The adherence rate of the appropriate RS-tDCS session was also investigated.

RESULTS

In within-group comparison, unlike the sham group, the real group showed significant improvement in K-MoCA (P_real=0.004 versus P_sham=0.132), particularly in patients with lower baseline K-MoCA (K-MoCA_10-17; P_real=0.001 versus P_sham=0.835, K-MoCA_18-25; P_real=0.060 versus P_sham=0.064) or with left hemispheric lesions (left; P_real=0.010 versus P_sham=0.454, right; P_real=0.106 versus P_sham=0.128). In between-group comparison, a significant difference was observed in K-MoCA in the lower baseline K-MoCA subgroup (K-MoCA_10-17; P_time×group=0.048), but no significant difference was found in other cognitive tests. The adherence rate of successful application of the RS-tDCS was 98.4%, and no serious adverse effects were detected.

CONCLUSIONS

RS-tDCS is a safe and feasible rehabilitation modality for post-stroke cognitive dysfunction. Specifically, RS-tDCS is effective in patients with moderate cognitive decline. Additionally, these data demonstrate the potential to enhance home-based cognitive training, although significant differences were not consistently found in between-group comparisons; therefore, further larger studies are needed.

REGISTRATION

URL: https://cris.nih.go.kr; Unique identifier: KCT0003427.

Alternative Payment Models and Associations With Stroke Outcomes, Spending, and Service Utilization: A Systematic Review

Stroke contributes an estimated $28 billion to US health care costs annually, and alternative payment models aim to improve outcomes and lower spending over fee-for-service by aligning economic incentives with high value care. This systematic review evaluates historical and current evidence regarding the impacts of alternative payment models on stroke outcomes, spending, and utilization. Included studies evaluated alternative payment models in 4 categories: pay-for-performance (n=3), prospective payments (n=14), shared savings (n=5), and capitated payments (n=14). Pay-for-performance models were not consistently associated with improvements in clinical quality indicators of stroke prevention. Studies of prospective payments suggested that poststroke spending was shifted between care settings without consistent reductions in total spending. Shared savings programs, such as US Medicare accountable care organizations and bundled payments, were generally associated with null or decreased spending and service utilization and with no differences in clinical outcomes following stroke hospitalizations. Capitated payment models were associated with inconsistent effects on poststroke spending and utilization and some worsened clinical outcomes. Shared savings models that incentivize coordination of care across care settings show potential for lowering spending with no evidence for worsened clinical outcomes; however, few studies evaluated clinical or patient-reported outcomes, and the evidence, largely US-based, may not generalize to other settings.

Association Between 2010 Medicare Reform and Inpatient Rehabilitation Access in People With Intracerebral Hemorrhage

Background

Evidence suggests intracerebral hemorrhage survivors have earlier recovery compared with ischemic stroke survivors. The Centers for Medicare and Medicaid Services prospective payment system instituted documentation rules for inpatient rehabilitation facilities (IRFs) in 2010, with the goal of optimizing patient selection. We investigated whether these requirements limited IRF and increased skilled nursing facility (SNF) use compared with home discharge.

Methods and Results

Intracerebral hemorrhage discharges to IRF, SNF, or home were estimated using GWTG (Get With The Guidelines) Stroke registry data between January 1, 2008, and December 31, 2015 (n=265 444). Binary hierarchical models determined associations between the 2010 Rule and discharge setting; subgroup analyses evaluated age, geographic region, and hospital type. From January 1, 2008, to December 31, 2009, 45.5% of patients with intracerebral hemorrhage had home discharge, 22.2% went to SNF, and 32.3% went to IRF. After January 1, 2010, there was a 1.06% absolute increase in home discharge, a 0.46% increase in SNF, and a 1.52% decline in IRF. The adjusted odds of IRF versus home discharge decreased 3% after 2010 (adjusted odds ratio [aOR], 0.97; 95% CI, 0.95–1.00). Lower odds of IRF versus home discharge were observed in people aged <65 years (aOR, 0.92; 95% CI, 0.89–0.96), Western states (aOR, 0.89; 95% CI, 0.84–0.95), and nonteaching hospitals (aOR, 0.90; 95% CI, 0.86–0.95). Adjusted odds of SNF versus home discharge increased 14% after 2010 (aOR, 1.14; 95% CI, 1.11–1.18); there were significant associations in all age groups, the Northeast, the South, the Midwest, and teaching hospitals.

Conclusions

The Centers for Medicare and Medicaid Services 2010 IRF prospective payment system Rule resulted in fewer discharges to IRF and more discharges to SNF in patients with intracerebral hemorrhage. Health policy changes potentially affect access to intensive postacute rehabilitation.

Association Between 2010 Medicare Reforms and Utilization of Postacute Inpatient Rehabilitation in Ischemic Stroke

OBJECTIVE

The aim of the study was to investigate whether the elimination of trial admissions and the initiation of documentation requirements, via the 2010 Centers for Medicare and Medicaid Services Inpatient Rehabilitation Facility Prospective Payment System Rule, limited inpatient rehabilitation facility access while increasing skilled nursing facility utilization compared with home discharge in ischemic stroke patients.

DESIGN

This is a retrospective observational study using Get with the Guidelines - Stroke hospital data between January 1, 2008 and December 31, 2015 (N = 1,643,553).

RESULTS

Between January 1, 2008 and December 31, 2009, 54.1% of patients went home, 25.4% to inpatient rehabilitation facility and 20.5% to skilled nursing facility. Between January 1, 2010 and December 31, 2015, there was a 1.4% absolute increase in home discharge, a 1.1% inpatient rehabilitation facility decline and a 0.3% skilled nursing facility decline.Within the 1.1% absolute decline in inpatient rehabilitation facility discharge, the adjusted odds of inpatient rehabilitation facility versus home discharge decreased 12% after 2010 Rule (adjusted odds ratio = 0.88, 95% confidence interval = 0.87-0.89, P < 0.0001). There was no statistically significant change in skilled nursing facility versus home discharge.Lower adjusted odds of inpatient rehabilitation facility discharge versus home discharge were identical across age groups and were present in all geographic regions.

CONCLUSIONS

In populations with ischemic stroke, the Centers for Medicare and Medicaid Services 2010 Inpatient Rehabilitation Facility Prospective Payment System Rule was associated with a 1.1% absolute decrease in inpatient rehabilitation facility discharge, with a concomitant increase in home discharge rather than to skilled nursing facility.

The Transition from the Hospital to an Inpatient Rehabilitation Setting for Neurologic Patients

Transitions of care from acute hospitalization to postacute rehabilitation settings evolved as a function of cost-saving changes to the Medicare Prospective Payment System. Restricted criteria for inpatient rehabilitation facility admission limited access for patients with severe physical and cognitive deficits. Once used as a resource-intense supplement to hospital care, skilled nursing facilities have metamorphosed into rehabilitation settings with limited nursing staff, lower intensity of therapies, and decreased community discharge rates. A collaborative approach to care transitions, using acute and postacute health care providers, provides the opportunity to improve this process. Early physiatry consultation is a strategy for patients with neurologic disease.

Facility and Geographic Variation in Rates of Successful Community Discharge After Inpatient Rehabilitation Among Medicare Fee-for-Service Beneficiaries

Importance

The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 mandated a quality measure of successful community discharge for postacute care services. Examining variation in performance nationally can help identify opportunities for improving patient-centered quality of care.

Objective

To examine US facility-level and geographic variation in rates of successful community discharges after inpatient rehabilitation.

Design, Setting, and Participants

This retrospective cohort study of Medicare claims data from December 31, 2013, through October 1, 2015, included 1154 inpatient rehabilitation facilities submitting claims to the Centers for Medicare & Medicaid Services and a total of 487 862 Medicare fee-for-service beneficiaries discharged from inpatient rehabilitation facilities. Analyses were performed from December 8, 2017, through September 11, 2018.

Main Outcomes and Measures

Successful community discharge as defined for the Discharge to Community-Post-Acute Care Inpatient Rehabilitation Facility Quality Reporting Program measure. To be considered a successful community discharge, patients had to discharge from the inpatient rehabilitation facility to the community (ie, home or self-care) and remain there without experiencing an unplanned rehospitalization or dying within the following 31 days. Centers for Medicare & Medicaid Services specifications were followed to identify the cohort, define the outcome, and calculate risk-standardized facility and state rates.

Results

Among the 487 862 patients included in the cohort, mean (SD) age was 76.4 (10.8) years, and 56.9% were female. The overall rate of successful community discharge after inpatient rehabilitation was 63.7% (95% CI, 63.6%-63.8%). Risk-standardized rates ranged from 42.9% to 83.6% across inpatient rehabilitation facilities. Two hundred sixteen facilities (18.7%) performed significantly better than the mean national rate and 203 (17.6%) performed significantly worse (P < .05). Risk-standardized state rates ranged from 55.9% to 73.3%. Rates were lowest in the Northeast (Massachusetts, 55.9%; New Hampshire, 57.0%) and highest in the West (Oregon, 70.3%; Hawaii, 73.3%).

Conclusions and Relevance

The observed variation suggests opportunities exist for improving this important, patient-centered national quality measure. Future research is needed to identify the aspects of care delivery and the community services and supports that facilitate successful community discharge. These findings can be used to guide care improvement efforts and further improve the consistency and quality of postacute care.

Home-based transcranial direct current stimulation plus tracking training therapy in people with stroke: an open-label feasibility study

Background

Transcranial direct current stimulation (tDCS) is an effective neuromodulation adjunct to repetitive motor training in promoting motor recovery post-stroke. Finger tracking training is motor training whereby people with stroke use the impaired index finger to trace waveform-shaped lines on a monitor. Our aims were to assess the feasibility and safety of a telerehabilitation program consisting of tDCS and finger tracking training through questionnaires on ease of use, adverse symptoms, and quantitative assessments of motor function and cognition. We believe this telerehabilitation program will be safe and feasible, and may reduce patient and clinic costs.

Methods

Six participants with hemiplegia post-stroke [mean (SD) age was 61 (10) years; 3 women; mean (SD) time post-stroke was 5.5 (6.5) years] received five 20-min tDCS sessions and finger tracking training provided through telecommunication. Safety measurements included the Digit Span Forward Test for memory, a survey of symptoms, and the Box and Block test for motor function. We assessed feasibility by adherence to treatment and by a questionnaire on ease of equipment use. We reported descriptive statistics on all outcome measures.

Results

Participants completed all treatment sessions with no adverse events. Also, 83.33% of participants found the set-up easy, and all were comfortable with the devices. There was 100% adherence to the sessions and all recommended telerehabilitation.

Conclusions

tDCS with finger tracking training delivered through telerehabilitation was safe, feasible, and has the potential to be a cost-effective home-based therapy for post-stroke motor rehabilitation.

Trial registration

NCT02460809 (ClinicalTrials.gov).

Postacute Care Setting, Facility Characteristics, and Poststroke Outcomes: A Systematic Review

OBJECTIVES

To synthesize research comparing poststroke health outcomes between patients rehabilitated in skilled nursing facilities (SNFs) and those in inpatient rehabilitation facilities (IRFs) as well as to evaluate relations between facility characteristics and outcomes.

DATA SOURCES

PubMed and CINAHL searches spanned January 1, 1998, to October 6, 2016, and encompassed MeSH and free-text keywords for stroke, IRF/SNF, and study outcomes. Searches were restricted to peer-reviewed research in humans published in English.

STUDY SELECTION

Observational and experimental studies examining outcomes of adult patients with stroke rehabilitated in an IRF or SNF were eligible. Studies had to provide site of care comparisons and/or analyses incorporating facility-level characteristics and had to report ≥1 primary outcome (discharge setting, functional status, readmission, quality of life, all-cause mortality). Unpublished, single-center, descriptive, and non-US studies were excluded. Articles were reviewed by 1 author, and when uncertain, discussion with study coauthors achieved consensus. Fourteen titles (0.3%) were included.

DATA EXTRACTION

The types of data, time period, size, design, and primary outcomes were extracted. We also extracted 2 secondary outcomes (length of IRF/SNF stay, cost) when reported by included studies. Effect measures, modeling approaches, methods for confounding adjustment, and potential confounders were extracted. Data were abstracted by 1 author, and the accuracy was verified by a second reviewer.

DATA SYNTHESIS

Two studies evaluating community discharge, 1 study evaluating the predicted probability of readmission, and 3 studies evaluating all-cause mortality favored IRFs over SNFs. Functional status comparisons were inconsistent. No studies evaluated quality of life. Two studies confirmed increased costs in the IRF versus SNF setting. Although substantial facility variation was described, few studies characterized sources of variation.

CONCLUSIONS

The few studies comparing poststroke outcomes indicated better outcomes (with higher costs) for patients in IRFs versus those in SNFs. Contemporary research on the role of the postacute care setting and its attributes in determining health outcomes should be prioritized to inform reimbursement system reform.

Importance and Difficulties of Pursuing rTMS Research in Acute Stroke

Although much research has been done on repetitive transcranial magnetic stimulation (rTMS) in chronic stroke, only sparse research has been done in acute stroke despite the particularly rich potential for neuroplasticity in this stage. We attempted a preliminary clinical trial in one active, high-quality inpatient rehabilitation facility (IRF) in the -United States. But after enrolling only 4 patients in the grant period, the study was stopped because of low enrollment. The purpose of this paper is to offer a perspective describing the important physiologic rationale for including rTMS in the early phase of stroke, the reasons for our poor patient enrollment in our attempted study, and recommendations to help future studies succeed. We conclude that, if scientists and clinicians hope to enhance stroke outcomes, more attention must be directed to leveraging conventional rehabilitation with neuromodulation in the acute phase of stroke when the capacity for neuroplasticity is optimal. Difficulties with patient enrollment must be addressed by reassessing traditional inclusion and exclusion criteria. Factors that shorten patients' length of stay in the IRF must also be reassessed at all policy-making levels to make ethical decisions that promote higher functional outcomes while retaining cost consciousness.

Framing new pathways in transformative exercise for individuals with existing and newly acquired disability

PURPOSE

This paper describes a continuum of customized exercise options for people with an existing and newly acquired disability or diagnosis referred to as the Transformative Exercise Framework.

BACKGROUND

The period directly after rehabilitation is a critical juncture where many individuals return to life with high rates of sedentary behavior. After rehabilitation discharge, people with newly acquired disability or diagnoses often never make the transition into usage of community-based exercise services that are tailored, safe and effective.

METHODS

Narrative review.

RESULTS

The Transformative Exercise Framework supports a patient-to-participant, rehab-to-wellness model that emphasizes a linkage between physical and occupational therapists and community-based exercise trainers. The four focus areas - Rehabilitation, Condition-specific Exercise, Fitness and Lifetime Physical Activity - emphasize a range of options for people with newly acquired disability and diagnoses, or for people with existing disability and/or chronic health conditions who have a new injury, secondary condition or are severely deconditioned.

CONCLUSION

The concept of transformative exercise is to support people with disabilities and diagnoses with a seamless restore-improve-prevent continuum of programs and services. This continuum connects individuals to rehabilitation and exercise professionals in a dynamic framework, which maximizes the expertise of both sets of professionals and provides the most effective interventions to achieve the greatest gains in health and function and/or to avoid future health decline. Implications for Rehabilitation Patients discharged from rehabilitation should be transformed into participants in lifelong physical activity through a continuum of health services, which we refer to as Transformative Exercise. Transformative exercise is a continuum of individually tailored exercise strategies/programs that aims to improve the function of underperforming systems, which inhibit community and/or lifelong physical activity participation. The Transformative Exercise Framework can be used by a therapist or exercise trainer to design a program that maximizes performance and time and is based on a specific process for identifying short and long term goals.

Inpatient rehabilitation centers and concern for increasing volume of ischemic stroke patients requiring rehabilitation

OBJECTIVES

To determine whether prolonged length of stay (pLOS) in ischemic stroke is related to delays in discharge disposition arrangement.

METHODS

We designed a retrospective study to compare patients with acute ischemic stroke who experienced pLOS to those who did not experience pLOS. Patients who have had acute ischemic stroke between July 2008 and December 2010 were included unless they arrived >48 hours after time last seen normal, had an unknown last seen normal, or experienced an in-hospital stroke. pLOS was defined in our prospective stroke registry (before the generation of this research question) as hospitalization extended for ≥ 24 hours more than necessary to determine neurologic stability and next level of care/disposition for a given patient. We characterized the frequency of each cause of pLOS and further investigated the destinations that were more frequently associated with pLOS among patients with delay resulting from arranging discharge disposition.

RESULTS

Of the 274 patients included, 106 (31.9%) had pLOS. Reasons for pLOS were discharge disposition (48.1%), non-neurologic medical complications (36.8%), delays in imaging studies (20.8%), awaiting procedure (10.4%), and neurologic complications (9.4%). Among patients with pLOS caused by delayed disposition, more than half were awaiting placement in an inpatient rehabilitation facility.

CONCLUSIONS

For the majority of our patients, pLOS was caused by acquired medical complications and delayed disposition, most commonly inpatient rehabilitation. Further efforts are needed to prevent complications and further investigation is necessary to identify the factors that may contribute to delayed discharge to inpatient rehabilitation facilities, which may include delayed planning or heightened scrutiny of insurance companies regarding their beneficiaries.

Shorter length of stay is associated with worse functional outcomes for medicare beneficiaries with stroke

BACKGROUND

Understanding of the potential impact that length of stay (LOS) may have on Medicare beneficiaries' poststroke discharge function and discharge destination since implementation of a prospective payment system is lacking.

OBJECTIVE

This study examined the trends and associations between LOS and discharge outcomes in Medicare beneficiaries with stroke treated in inpatient rehabilitation facilities (IRFs).

DESIGN

A serial, cross-sectional analysis of the Inpatient Rehabilitation Facility Patient Assessment Instrument dataset was conducted. The sample consisted of 371,211 patients with stroke who were over 65 years of age in all IRFs in the United States between January 1, 2002, and June 30, 2007.

METHODS

Annual trends for means of LOS, admission and discharge Functional Independence Measure (FIM) scores, and percent community discharge were examined using generalized estimating equations (GEEs) with facility level control and post hoc testing. The association between discharge FIM scores and LOS was examined using a continuous, multivariate GEE model. The association between community discharge and LOS was examined using a logistic, multivariate GEE model.

RESULTS

Time trends showed mean LOS decreased 1.8 days; admission and discharge FIM scores declined 4.4 points and 3.6 points, respectively; and mean community discharges declined 5.4%. Controlling for study year and covariates, each day was associated with an increase of 0.50 discharge FIM points (95% confidence interval=0.48, 0.52). Each day also was associated with a 0.3% decrease in odds of community discharge (95% confidence interval=0.994, 0.999).

LIMITATIONS

Reliability and validity of the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) are lacking. Results may have been biased by a lack of control at the patient and facility levels.

CONCLUSIONS

Medicare beneficiaries with stroke treated in IRFs experienced shorter LOS, had worsening admission and discharge function, and had fewer community discharges. Worsening admission function and shorter LOS may contribute to worsening discharge outcomes, which may indicate a lack of readiness for IRF treatment and that facility-level factors may be playing a role in shorter LOS.

Restructuring a rehabilitation program for older adults: effects on patient outcomes and staff perspectives

The purpose of this mixed-methods research study was to examine the impact of organizational change on patient outcomes and staff experiences in a rehabilitation program for older adults. Program restructuring focused on reducing patient length of stay and increasing admissions to the rehabilitation program. Study findings revealed that patients admitted after restructuring, as compared to the time period just prior, experienced shorter lengths of stay yet made similar progress towards rehabilitation goals. The average discharge Functional Independence Measure (FIM) scores between the two time periods were not significantly different. Yet FIM efficiency scores improved after the restructuring. With this reorganization, rehabilitation staff reported working harder to help patients achieve satisfactory outcomes, although initially staff reported lower morale. Findings extend the current literature and have practical implications for health care professionals interested in facilitating successful organizational change.

Validity of the Sitting Balance Scale in older adults who are non-ambulatory or have limited functional mobility

OBJECTIVE

To determine whether the Sitting Balance Scale is an acceptable alternative to the Trunk Impairment Scale for measuring the construct of sitting balance, to examine relationships with other clinical outcomes and to establish discriminative validity.

DESIGN

Prospective descriptive methodological study.

SETTING

Acute care, inpatient rehabilitation, skilled nursing facility and home health.

PARTICIPANTS

Patients receiving physical therapy (N = 98; n = 20 acute care, n = 18 inpatient rehabilitation, n = 30 skilled nursing facility, n = 30 home setting) mean (SD) age, 80.5 (7.9) years. Nineteen were non-ambulatory and 79 had limited functional mobility with Timed Up and Go scores ≥20 seconds.

MAIN MEASURES

Sitting Balance Scale, Trunk Impairment Scale, Timed Up and Go, length of stay and setting specific clinical measures of sitting balance (OASIS-C M1850; MDS G-3b).

RESULTS

Moderate association between ambulatory status and sitting balance measures (Sitting Balance Scale r = 0.67, Trunk Impairment Scale r = 0.61; P = 0.0001). Moderate to strong relationships between Sitting Balance Scale, Trunk Impairment Scale and clinical outcomes varying by setting. MANOVA results revealed differences between ambulators and non-ambulators and among diagnostic categories for both instruments (P < 0.001).

CONCLUSIONS

The Sitting Balance Scale is comparable to the Trunk Impairment Scale for measuring sitting balance in older adults who are non-ambulatory or have limited mobility.

The crisis of stroke: experiences of patients and their family caregivers

PURPOSE

Approximately 4.8 million stroke survivors are living in the community with some level of disability requiring the assistance of family caregivers. Stroke family caregivers are often unprepared for the demands required of them. The purpose of this grounded theory study was to explore the needs of stroke patients and their family caregivers as they transitioned through the stroke care continuum from acute care to inpatient rehabilitation to home.

METHODS

Thirty-eight participants, 19 recovering stroke patients (11 male, 8 female), 15 primary family caregivers (14 spouses, 1 mother), and 4 adult children were interviewed during their stay at a rehabilitation facility and within 6 months of discharge. Interview questions were loosely structured and focused on the stroke experience and how patients and caregivers were managing postdischarge. Data were analyzed using dimensional and comparative analysis.

RESULTS

Findings were organized in a conceptual framework illustrating the trajectory of the crisis of stroke. Stroke survivors and their caregivers faced enormous challenges as they moved through 3 phases of the trajectory: the stroke crisis, expectations for recovery, and the crisis of discharge. Findings from this study suggest that as caregivers move through the phases of the trajectory, they do not have a good understanding of the role to which they are committing, and they are often underprepared to take on even the basic tasks to meet the patients' needs on discharge.

CONCLUSION

Stroke survivors and their caregivers do not have adequate time to deal with the shock and crisis of the stroke event, let al.one the crisis of discharge and all of the new responsibilities with which they must deal.

Ethical issues in inpatient rehabilitation length of stay determination

The intersection of financial considerations and patient care is fraught with conflicts of interest and, frequently, with accompanying ethical dilemmas. Inpatient rehabilitation is a unique component of the health care delivery system and presents a distinctive set of ethical dilemmas, including issues of patient autonomy and decision making. This article focuses on the particular issue of resource allocation and the determination of inpatient rehabilitation hospital length of stay. The challenges posed by uncertain endpoints as goals of rehabilitative care and the psychological aspects of recovery from major disabling illness are among the issues confronted by health care providers in the rehabilitation setting when they try to balance patient and institutional goals.

Complex versus simple ankle movement training in stroke using telerehabilitation: a randomized controlled trial

BACKGROUND

Telerehabilitation allows rehabilitative training to continue remotely after discharge from acute care and can include complex tasks known to create rich conditions for neural change.

OBJECTIVES

The purposes of this study were: (1) to explore the feasibility of using telerehabilitation to improve ankle dorsiflexion during the swing phase of gait in people with stroke and (2) to compare complex versus simple movements of the ankle in promoting behavioral change and brain reorganization.

DESIGN

This study was a pilot randomized controlled trial.

SETTING

Training was done in the participant's home. Testing was done in separate research labs involving functional magnetic resonance imaging (fMRI) and multi-camera gait analysis.

PATIENTS

Sixteen participants with chronic stroke and impaired ankle dorsiflexion were assigned randomly to receive 4 weeks of telerehabilitation of the paretic ankle.

INTERVENTION

Participants received either computerized complex movement training (track group) or simple movement training (move group).

MEASUREMENTS

Behavioral changes were measured with the 10-m walk test and gait analysis using a motion capture system. Brain reorganization was measured with ankle tracking during fMRI.

RESULTS

Dorsiflexion during gait was significantly larger in the track group compared with the move group. For fMRI, although the volume, percent volume, and intensity of cortical activation failed to show significant changes, the frequency count of the number of participants showing an increase versus a decrease in these values from pretest to posttest measurements was significantly different between the 2 groups, with the track group decreasing and the move group increasing.

LIMITATIONS

Limitations of this study were that no follow-up test was conducted and that a small sample size was used.

CONCLUSIONS

The results suggest that telerehabilitation, emphasizing complex task training with the paretic limb, is feasible and can be effective in promoting further dorsiflexion in people with chronic stroke.