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.

Are Stroke Survivors Discharged to the Recommended Postacute Setting?

OBJECTIVE: To examine the processes and barriers involved in providing postdischarge stroke care. DESIGN: Prospective study of discharge planners' (DP) and physical therapists' (PT) interpretation of factors contributing to patients' discharge destination. SETTING: Twenty-three hospitals in the northeastern United States. PARTICIPANTS: After exclusions, data on patients (N=427) hospitalized with a primary diagnosis of stroke between May 2015 and November 2016 were examined. Of the patients, 45% were women, and the median age was 71 years. DPs and PTs caring for these patients were queried regarding the selection of discharge destination. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Comparison of actual discharge destination for stroke patients with the destinations recommended by their DPs and PTs. RESULTS: In total, 184 patients (43.1%) were discharged home, 146 (34.2%) to an inpatient rehabilitation facility, 94 (22.0%) to a skilled nursing facility, and 3 (0.7%) to a long-term acute care hospital. DPs and PTs agreed on the recommended discharge destination in 355 (83.1%) cases. The actual discharge destination matched the DP and PT recommended discharge destination in 92.5% of these cases. In 23 cases (6.5%), the patient was discharged to a less intensive setting than recommended by both respondents. In 4 cases (1.1%), the patient was discharged to a more intensive level of care. In 2 cases (0.6%), the patient was discharged to a long-term acute care hospital rather than an inpatient rehabilitation facility as recommended. Patient or family preference was cited by at least 1 respondent for the discrepancy in discharge destination for 13 patients (3.1%); insurance barriers were cited for 9 patients (2.3%). CONCLUSIONS: Most stroke survivors in the northeast United States are discharged to the recommended postacute care destination based on the consensus of DP and PT opinions. Further research is needed to guide postacute care service selection.

Use of a standardized assessment to predict rehabilitation care after acute stroke.

OBJECTIVE: To pilot a program of formal assessment of rehabilitation needs and predictors of referral to rehabilitation. DESIGN: A prospective pilot project to collect standardized measures of stroke severity and function: National Institutes of Health Stroke Scale, premorbid modified Rankin scale, Short Portable Mental Status Questionnaire, and Barthel Index (BI). These were collected in addition to routine data in the Get With The Guidelines-Stroke registry. Logistic regression was used to examine predictors of referral to any institution-based rehabilitation versus discharge home and referral to an inpatient rehabilitation facility (IRF) versus a skilled nursing facility (SNF). SETTING: Twenty-two hospitals within the Northeast Cerebrovascular Consortium (located in the northeastern United States). PARTICIPANTS: Data were collected on individuals with acute ischemic and hemorrhagic stroke (N=736). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Discharge disposition location. RESULTS: The BI score was recorded in 736 (81%) patients. In multivariable analyses, a higher BI score (85-100) was the only factor associated with return home versus need for institution-based rehabilitation (P<.001). Among patients discharged to IRF versus SNF, discharge to IRF was less likely in older patients (odds ratio [OR], .96; confidence interval [CI], .94-.98; P<.001) and in those with prestroke disability (modified Rankin scale score, 2-5) (OR, .47; CI, .28-.78; P=.004) and more likely in those with moderate-severe (BI score, 25-40; OR, 3.26; CI, 1.45-7.30; P=.004) or moderate (BI score, 45-60; OR, 2.47; CI, 1.17-5.21; P=.018) activities of daily living (ADL) impairment. CONCLUSIONS: Formal standardized assessment of rehabilitation needs was feasible in this pilot project. Patients' sociodemographic characteristics, premorbid function, and ADL impairment discriminated better between discharge home and institution-based rehabilitation than between IRF and SNF. Selection of IRF versus SNF appears to be influenced either by unmeasured clinical characteristics of individuals with stroke or by nonclinical factors, such as cost, geography, referral relationships, or IRF availability.

Selection of Postacute Stroke Rehabilitation Facilities: A Survey of Discharge Planners From the Northeast Cerebrovascular Consortium (NECC) Region.

The process of determining the level of care and specific postacute care facility for stroke patients has not been adequately studied. The objective of this study was to better understand the factors that influence postacute care decisions by surveying stroke discharge planners. Requests were sent to discharge planners at 471 hospitals in the Northeast United States to complete an online survey regarding the factors impacting the selection of postacute care. Seventy-seven (16%) discharge planners completed the online survey. Respondents were mainly nurses and social workers and 73% reported ≥20 years healthcare experience. Patients and families were found to be significantly more influential than physicians (P < 0.001) and other clinicians (P = 0.04) in influencing postdischarge care. Other clinicians were significantly more influential than physicians (P < 0.001). Insurance and quality of postacute care were the factors likely to most affect the selection of postacute care facility. Insurance was also identified as the greatest barrier in the selection of level of postacute care (70%; P < 0.001) and specific postacute care facility (46%; P = 0.02). More than half reported that pressure to discharge patients quickly impacts a patients' final destination. Nonclinical factors are perceived by discharge planners to have a major influence on postacute stroke care decision making.