Vertical Planning for Stroke Care

in PM&RRandie M. Black-Schaffer, M.D.

Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston MA

Stroke Outcomes – The Challenge• 10% of stroke survivors recover almost

completely • 25% recover with minor impairments • 40% experience moderate to severe

impairments that require special care • 10% require care in a nursing home or other

long-term facility • 15% die shortly after the stroke

National Stroke Association, as cited on www.ninds.nih.gov/disorders/stroke/stroke_rehabilitation

Vertical Planning for Stroke

• Position the specialty to adopt a pivotal role in providing post-acute care for stroke patients

• Develop initiatives to improve post-acute stroke care and enhance the role of PM&R in stroke care

• Harness the resources of AAPMR to help accomplish these goals

Vertical Planning Concept

Stroke SpinePractice

LegislationAdvocacyEducation Communications

History of Vertical Planning at AAPMR

• 2011 ‘Positioning the Specialty’ summit– Drill down on specific areas of care vs. addressing

in aggregate– Move away from ‘horizontal’ planning to a vertical

approach

• 2012-13 focus areas identified and prioritized by Board of Governors

• 2013 Stroke and Spine pilot groups meet

Vertical Planning for Stroke Rehabilitation: Vision - December, 2014

Physiatrists will be pivotal in defining stroke rehabilitation patient pathways across the continuum of care (acute, post-acute, sub-acute, outpatient) to ensure optimal patient function. Physiatrists will work across the continuum, caring for stroke patients in all settings. Physiatrists will play a role in the transitions of care across this continuum, fostering relationships with other care providers to ensure that patients with ongoing functional needs receive appropriate care.

Vertical Strategic Planning for Stroke Rehabilitation – AAPMR taskforce

• Randie Black-Schaffer, MD (Chair) Spaulding Rehabilitation Hospital/Harvard Medical School, Boston

• Joe Burris, MD University of Missouri, Columbia

• Steven Flanagan, MD NYU Langone Medical Center, New York• Darryl Kaelin, MD Frazier Rehabilitation Institute/University of Louisville, Kentucky

• Joel Stein, MD Columbia University Medical Center/NY-Presbyterian Hospital/Weill

Cornell Medical College, New York City

VP Plan-Practice & Advocacy1. Develop an AAPMR consensus statement on

optimal post-acute stroke patient pathways for stroke patients – Stroke Pathways Task Force

2. Develop innovative practice models for physiatrists caring for stroke patients – SNF, Outpatient, ICU

3. Work toward inclusion in national guidelines of standards for stroke patient care throughout the initial episode of care and beyond.

VP Plan - Education1. Create medical/ practice/regulatory educational tools to enable physiatrists to care for stroke patients in all post-acute settings

2. Promote PM&R training in all post-acute settings

3. Create education tools for patients, families, hospital staffs about the post-acute continuum of stroke care and physiatry’s role in these settings

VP Plan-Communication1. Build awareness within PM&R of recommended patient pathways and practice options

2. Build awareness across related specialty organizations, e.g. ASA, AAN, of the AAPMR optimal patient centered model for post-acute stroke care

3. Educate the public about the post-acute care continuum and physiatry’s role in assuring optimal care for stroke patients across the continuum

Innovative Practice models for PM&R in stroke care

• Skilled Nursing Facility Stroke Rehabilitation

• Long-Term Outpatient follow-up• Consultation in the neuro ICU

Skilled Nursing Facility

• 6-7% of pts in SNF rehab are there for stroke now (Dobson/Davanzo 2014)

• More in the future?• LOS in SNF for stroke 32.1 days(Dobson/Davanzo 2014)

• CMS requirements: – Skilled therapy 5x/wk - no time requirement– MD visit minimum q 30 days, and as ‘medically

necessary’– RN present 8hrs/day

Value added by PM&R for stroke patients in SNF Rehab

Consultant to rehabilitation therapists Bowel/bladder Skin integrity Pain management Spasticity/hypertonicity management Adjustment and mood disorders Durable medical equipment Orthotics and assistive devices Education and training for patient and caregivers Goal of community discharge

Challenges for PM&R in SNF Rehab

• Consultant vs. attending• Ancillary services• Nursing, therapy staffing and resources• Team process

– Assessment – MDS– Care plan

Outpatient PM&R Management

• 4.6 million community dwelling stroke survivors in US.

• Long-term follow-up for– Rehab therapy oversight– Spasticity– Pain– Function– Impairment– Orthotics/Assistive devices/DME

Challenges for PM&R in Outpatient stroke management

• Many issues to address – too little time• No standard of care for longterm

management of stroke sequelae• Opportunity for Telehealth visits?

Physiatry in the Neuro ICU

– Early Mobilization– Spasticity and contracture management– Eval and management of Critical Illness

myopathy/polyneuropathy– Use and timing of neurostimulants– Sleep/Wake cycle management– Neurogenic bowel/bladder– Barriers to rehabilitation candidacy

Thank you! rblackschaffer@partners.org

Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston MA