Stroke care in long-term care facilities in southwestern Ontario

Coverage and equity of essential care services among stroke survivors in the Western Province of Sri Lanka: a community-based cross-sectional study

BACKGROUND

Stroke survivors require continuing services to limit disability. This study assessed the coverage and equity of essential care services received during the first six months of post-stroke follow-up of stroke survivors in the Western Province of Sri Lanka.

METHODS

A multidisciplinary team defined the essential post-stoke follow-up care services and agreed on a system to categorize the coverage of services as adequate or inadequate among those who were identified as needing the said service. We recruited 502 survivors of first ever stroke of any type, from 11 specialist hospitals upon discharge. Six months following discharge, trained interviewers visited their homes and assessed the coverage of essential services using a structured questionnaire.

RESULTS

Forty-nine essential post-stroke follow-up care services were identified and categorized into six domains: monitoring of risk conditions, treatment, services to limit disabilities, services to prevent complications, lifestyle modification and supportive services. Of the recruited 502 stroke survivors, 363 (72.3%) were traced at the end of 6 months. Coverage of antiplatelet therapy was the highest (97.2% (n = 289, 95% CI 95.3- 99.1)) while referral to mental health services (3.3%, n = 12, 95% CI 1.4-5.1) and training on employment for the previously employed (2.2%, n = 4, 95% CI- 0.08-4.32), were the lowest among the six domains of care. In the sample, 59.8% (95% CI 54.76-64.48) had received an 'adequate' level of essential care services related to treatment while none received an 'adequate' level of services in the category of support services. Disaggregated service coverage by presence and type of limb paralysis within the domain of services to prevent complications, and by sex and education level within the domain of education level, show statistically significant differences (p < 0.05).

CONCLUSIONS

Apart from treatment services to limit disabilities, coverage of essential care services during the post-stroke period was inadequate. There were no apparent inequities in the coverage of vast majority of services. However focused policy decisions are required to address these gaps in services.

Timely access to inpatient rehabilitation after stroke: a qualitative study of perceived barriers and potential solutions in Ontario, Canada

PURPOSE

Stroke units have been established as best practice care, in part because they offer timely initiation of rehabilitation. Experts in Ontario, Canada recommend that eligible patients be transferred to inpatient rehabilitation (on average) by day 5 after ischemic stroke and day 7 after a hemorrhagic stroke. This study explores perceived barriers to implementation of these recommendations and potential solutions.

METHOD

Exploratory focus groups were held with stakeholders from five geographically diverse regions across Ontario between September 2011 and January 2012. Participants were asked to consider the recommendations, list perceived barriers and to collectively discuss potential solutions. Data analysis included coding of transcribed data, sorting material to identify themes and confronting themes with a formalized body of knowledge.

RESULTS

Barriers identified by participants fell into three categories: patient-centered, clinician-focused and resource or system based, within these, specific challenges included managing patients' medical and emotional readiness for rehabilitation, timely completion of medical tests, staff comfort in discharging patients, dedicated transportation and funding-related concerns.

CONCLUSIONS

The structure of Ontario's health care system presents challenges to early transfer of stroke patients to inpatient rehabilitation, yet the stakeholders consulted in this study felt that these could be addressed with proper planning, improved coordination and targeted investment. Implications for rehabilitation Stroke units are a well-established best practice in stroke care and timely access to rehabilitation is a key component of their effectiveness. Stroke experts in Ontario, Canada recommend transfer of suitable patients to inpatient rehabilitation on day 5 and day 7, on average, after ischemic and hemorrhagic stroke, respectively. Stakeholders report that meeting these targets may require some adjustments to local processes of care, many of which can be achieved with little to no financial investment.

A systematic review of studies investigating the care of stroke survivors in long-term care facilities

PURPOSE

The burden of stroke is immense, with approximately 30 million stroke survivors globally. Approximately one-quarter of residents in long-term care (LTC) facilities are stroke survivors. This review aims to integrate the existing knowledge from the literature and elucidate themes around the care of stroke survivors in LTC facilities.

METHOD

A systematic search was performed in PubMed, Ovid MEDLINE, the Cochrane Library and CINAHL. Articles that met the eligibility criteria were selected. Synthesis of results according to similar themes was performed.

RESULTS

A total of 1920 articles were screened for eligibility, of which 22 met the eligibility criteria. Of the 22 articles selected, five and 17 articles comprised interventional and observational studies, respectively. Three themes were identified: rehabilitation, stroke specific care and secondary stroke drug prevention. These were found to be lacking within LTC facilities. There is also a dearth of interventional studies in stroke survivors from LTC facilities.

CONCLUSIONS

The care of stroke survivors in LTC facilities is lacking in rehabilitation, stroke specific care and secondary stroke prevention. This needs to be addressed through conducting further research to build a strong body of evidence to influence change in the care of this vulnerable group of patients. Implications for Rehabilitation Care of stroke survivors in long-term care facilities Stroke survivors make up almost a quarter of residents in long-term care facilities. They suffer from functional impairments and many other disabilities as a result of more severe stroke, precluding them from living in their own homes. Rehabilitation, stroke-specific care and secondary stroke prevention for stroke survivors are lacking in long-term care facilities despite strong evidence showing benefits for these interventions in stroke survivors living in the community. Interventions to address the unmet need in stroke survivors living in long-term care facilities are vital for optimal care of this vulnerable group of patients.

Can short-term residential care for stroke rehabilitation help to reduce the institutionalization of stroke survivors?

Background

Stroke survivors may not be receiving optimal rehabilitation as a result of a shortage of hospital resources, and many of them are institutionalized. A rehabilitation program provided in a short-term residential care setting may help to fill the service gap.

Objectives

The primary objectives of this study were, first, to examine whether there were significant differences in terms of rehabilitation outcomes at 1 year after admission to the rehabilitation program (defined as baseline) between those using short-term residential care (intervention group) and those using usual geriatric day hospital care (control group), and, second, to investigate whether lower 1-year institutionalization rates were observed in the intervention group than in the control group.

Participants

155 stroke survivors who completed at least the first follow-up at 4 months after baseline.

Intervention

The intervention group was stroke survivors using self-financed short-term residential care for stroke rehabilitation. The control group was stroke survivors using the usual care at a public geriatric day hospital.

Measurements

Assessments were conducted by trained research assistants using structured questionnaires at baseline, 4 months, and 1 year after baseline. The primary outcome measures included Modified Barthel Index score, Mini-Mental Status Examination score, and the institutionalization rate.

Results

Cognitive status (as measured by Mini-Mental Status Examination score) of patients in both groups could be maintained from 4 months to 1 year, whereas functional status (as measured by Modified Barthel Index score) of the patients could be further improved after 4 months up to 1 year. Meanwhile, insignificant between-group difference in rehabilitation outcomes was observed. The intervention participants had a significantly lower 1-year institutionalization rate (15.8%) than the control group (25.8%).

Conclusion

Short-term residential care for stroke rehabilitation promoted improvements in rehabilitation outcomes comparable with, if not better than, the usual care at geriatric day hospital. Furthermore, it had a significantly lower 1-year institutionalization rate. This type of service could be promoted to prevent institutionalization.

A quasi-experimental study on a new service option for short-term residential care of older stroke patients

We conducted a quasi-experimental study to compare the effectiveness of a new short-term residential care option for stroke rehabilitation with that of usual day hospital care. Primary data were collected from stroke patients and their caregivers from June 2009 to May 2012. New service option users and their caregivers were recruited for the intervention group, while users of usual public geriatric day hospital care and their caregivers were recruited for the control group. The primary outcome measures were Modified Barthel Index (MBI) and Mini-Mental Status Examination (MMSE) scores. Trained research assistants assessed the outcome measures at the beginning of the rehabilitation program (baseline) and at a 4-month follow-up. Sixty and 128 stroke patients were recruited for the intervention and control groups, respectively; 50 and 105 participants, respectively, completed the 4-month follow-up. At 4-month follow-up, the intervention group had an increased MBI score of 15.3 (95% confidence interval [CI] 10.8–19.8) and an MMSE score of 1.3 (95% CI 0.4–2.1). In comparison, the control group had an increased MBI score of 13.3 (95% CI 9.7–16.8) and an MMSE score of 1.1 (95% CI 0.4–1.9). Both groups showed a significant improvement in MBI and MMSE scores after 4 months, and there was no significant between-group difference. To conclude, the new service option and the usual care option showed similar improvement in rehabilitation outcomes at 4 months after baseline. Initiatives to provide alternative care options on a user-pay model should be encouraged to ensure a sustainable health care system.

Care transitions for older patients with musculoskeletal disorders: continuity from the providers' perspective

Introduction

Care transitions are a common and frequently adverse aspect of health care, resulting in a high-risk period for both care quality and patient safety. Patients who have complex care needs and undergo treatment in multiple care settings, such as older patients with musculoskeletal disorders, may be at higher risk for poor care transitions.

Methods

Key informant interviews were used to gather in-depth information on transitional care issues, particularly those which impact informational continuity, from the perspective of a range of health professionals (η=17) in care settings relevant to the care continuum of older patients with hip fractures.

Results

Three transitional care themes were identified; medical complexity impacts care trajectories, larger circles of care can be both beneficial and challenging, and a variety of channels and modes are required for meaningful information exchange. Many issues cut across each care setting, and address challenges to informational continuity among and between health care providers, patients, and caregivers.

Conclusions

Medical complexity enlarges the circle of care which challenges care continuity. There may be fundamental elements which, regardless of care setting, strengthen transitional care quality. Standardized transitional care processes might help to offset informational discontinuity across care settings as a result of this population’s larger circles of care.