The development of indicators to measure the quality of care in geriatric rehabilitation.

Quality of care is an essential aspect of geriatric rehabilitation. Usually, there are national standards for the quality of care or indicators to measure the quality of care. However, this is not the case for geriatric rehabilitation. Therefore, the aim of this study was to develop structure, process, and outcome indicators to measure the quality of geriatric rehabilitation. To develop quality indicators for geriatric rehabilitation, a literature search was performed to identify indicators for all types of rehabilitation that can also be suitable for geriatric rehabilitation. Thereafter, in the qualitative phase, different stakeholders were inte. Indicators from the literature and indicators developed based on the interviews were merged and processed in a questionnaire. Through this questionnaire, elderly care physicians and managers of geriatric rehabilitation facilities were asked to rate the indicators on relevance and feasibility. Indicators that were considered relevant and feasible by the respondents were included in the final quality indicator set for geriatric rehabilitation. Thirty-six indicators suitable for geriatric rehabilitation were identified from the literature. Additionally, 55 quality indicators were developed based on the interviews. Merging the indicators and omitting duplicates resulted in 69 quality indicators. Analysis of the data from the questionnaires resulted in a final set of 27 quality indicators for geriatric rehabilitation that consists of 17 structure, 8 process, and 2 outcome indicators. This study contributes to the quality of geriatric rehabilitation by providing a first set of quality indicators ready to use in practice. Follow-up research is recommended and may include an assessment of the applicability, reliability, and validity of the developed indicator set.

Determinants of geriatric patients' quality of life after stroke rehabilitation.

OBJECTIVES: Geriatric patients' physical disabilities, dependency on care, and possible psychological ill-being may negatively affect both the patient's quality of life and the informal caregiver burden. Focusing on this interrelationship which can be particularly prominent in geriatric patients with stroke, the objective of this study was to identify determinants of patients' quality of life and informal caregiver burden. METHOD: This is a prospective, multicentre, cohort study. Data were collected in 84 geriatric home-dwelling patients with stroke three months after their rehabilitation period in skilled nursing facilities (SNFs). We assessed patients' quality of life, depressive complaints, neuropsychiatric symptoms, balance, (instrumental) activities of daily living, and informal caregiver burden. Linear regression models were constructed to study the association between the variables. RESULTS: For several domains, high quality of life of these geriatric patients was associated with high functional independence, less neuropsychiatric symptoms, and less depressive complaints. Informal caregiver burden was not associated with patients' quality of life, but patients' neuropsychiatric symptoms were a significant determinant of high informal caregiver burden. CONCLUSION: The presence of neuropsychiatric symptoms (more specifically depressive complaints) negatively affects the quality of life of geriatric patients. Their neuropsychiatric symptoms also affect caregiver burden. Health care professionals in SNFs can play an important role in providing the necessary psychosocial support and aftercare.

Time use of stroke patients with stroke admitted for rehabilitation in Skilled Nursing Facilities.

PURPOSE: To describe the time use of patients with stroke in five Skilled Nursing Facilities (SNFs) in the Netherlands, focusing on the time spent on therapeutic activities, nontherapeutic activities, interaction with others, and the location where the activities took place. Evidence suggest that task-oriented interventions are the most effective for patients with stroke and that some of these interventions are relevant and feasible for use by nurses. The question arises to what extent elderly patients who had a stroke and rehabilitate in a SNF receive therapeutic training and engage in therapeutic activities. DESIGN: Descriptive, observational design. Therapeutic and nontherapeutic activities of patients were observed at 10-minute intervals during one weekday (8 a.m.-4:30 p.m.) using behavioral mapping. FINDINGS: Forty-two patients with stroke with a mean age of 76 years participated in the study. The patients spent 56% of the day on therapeutic activities, whereas 44% of the day was spent on nontherapeutic activities. Most therapeutic time was spent on nursing care (9%) and physical therapy (4%). Patients stayed an average 41% of the day in their own room and were alone 49% of the day. Therapeutic time use was significantly related to improved functional status, patients with higher functional status spent more time on therapeutic activities. CONCLUSION: Patients spent more than half of the day on therapeutic activities. CLINICAL RELEVANCE: Nurses are faced with the challenge of activating patients with stroke and to assist them to engage in purposeful task-oriented exercises including daily activities. Thereby better rehabilitation results and recovery of patients may be reached.

A Qualitative Study Exploring Rehabilitant and Informal Caregiver Perspectives of a Challenging Rehabilitation Environment for Geriatric Rehabilitation.

There is a trend toward formalization of the rehabilitation process for older rehabilitants in a Challenging Rehabilitation Environment (CRE). This concept involves the comprehensive organization of care, support, and environment in rehabilitation wards. So far, literature about the principles of CRE is scarce. This study aims to explore the opinions of rehabilitants and informal caregivers regarding CRE, through a qualitative study between 2019 and 2020. Three telephone interviews were conducted with informal caregivers, and also 3 focus groups with 15 rehabilitants and 3 informal caregivers, all with recent experience in rehabilitation. Nine themes emerged regarding the rehabilitation process: (1) rehabilitant (attention for resilience, motivation, cognitive and emotional aspects), (2) rehabilitant centered (goal setting, physical and cognitive functioning and coping), (3) informal caregivers (involving and attention for resilience and relation), (4) communication (aligning the rehabilitation process), (5) exercise (increasing intensity by using task-oriented exercise, patient-regulated exercise, and group training), (6) peer support (learning experiences and recognition), (7) daily schedule (influence on the planning and activities outside therapy), (8) nutrition (energy for rehabilitation), and (9) eHealth (makes rehabilitation more challenging and fun). Regarding organizational processes, 4 themes were identified: (1) environmental aspects (single bedrooms, shared room for activities and therapy options on the ward), (2) staff aspects (small team with an emphatic supportive and motivating attitude), (3) organizational aspects (organized in an efficient way), and (4) return home (the discharge process should be well prepared for instance with home visits). Organizing excellent rehabilitation care requires a thorough understanding of the concept of CRE, as it is a complex and comprehensive concept that concerns the whole rehabilitation process. Its effectiveness and efficiency should be researched in prospective studies.

A Qualitative Study Exploring Professional Perspectives of a Challenging Rehabilitation Environment for Geriatric Rehabilitation.

There is a trend towards the formalization of the rehabilitation process for older rehabilitants in a Challenging Rehabilitation Environment (CRE). This concept involves the comprehensive organization of care, support, and environment on rehabilitation wards. So far, literature on the principles of the CRE is scarce. This study aims to explore the perspectives regarding the CRE of healthcare professionals through a qualitative study. Therefore, between 2018 and 2020, six international and 69 Dutch professionals were interviewed in focus groups, and 180 professionals attended workshops on two Dutch congresses. Data were thematically analyzed using ATLAS.ti. Seven themes emerged regarding the rehabilitation processes: (1) rehabilitant (attention for cognitive functioning and resilience); (2) goals (setting personal goals); (3) exercise (increasing exercise intensity); (4) daily schedule (following the daily rhythm); (5) involving the client system (involving informal caregivers); (6) nutrition (influences rehabilitation capability); and (7) technology (makes rehabilitation more safe and challenging). Regarding organizational aspects, four main themes were identified: (1) environmental aspects (encourages exercises); (2) staff aspects (interdisciplinary team); (3) organizational aspects (implementing CRE requires a shared vision); and (4) factors outside the ward (a well-prepared discharge process). To offer effective rehabilitation, all elements of the CRE should be applied. To improve the CRE, specific interventions need to be developed and implemented. Consequently, the effectiveness and efficiency of the CRE need to be measured with validated tools.

Factors Influencing the Introduction of Value-Based Payment in Integrated Stroke Care: Evidence from a Qualitative Case Study.

Background: To address issues related to suboptimal insight in outcomes, fragmentation, and increasing costs, stakeholders are experimenting with value-based payment (VBP) models, aiming to facilitate high-value integrated care. However, insight in how, why and under what circumstances such models can be successful is limited. Drawing upon realist evaluation principles, this study identifies context factors and associated mechanisms influencing the introduction of VBP in stroke care. Methods: Existing knowledge on context-mechanism relations impacting the introduction of VBP programs (in real-world settings) was summarized from literature. These relations were then tested, refined, and expanded based on a case study comprising interviews with representatives from organizations involved in the introduction of a VBP model for integrated stroke care in Rotterdam, the Netherlands. Results: Facilitating factors were pre-existing trust-based relations, shared dissatisfaction with the status quo, regulatory compatibility and simplicity of the payment contract, gradual introduction of down-side risk for providers, and involvement of a trusted third party for data management. Yet to be addressed barriers included friction between short- and long-term goals within and among organizations, unwillingness to forgo professional and organizational autonomy, discontinuity in resources, and limited access to real-time data for improving care delivery processes. Conclusions: Successful payment and delivery system reform require long-term commitment from all stakeholders stretching beyond the mere introduction of new models. Careful consideration of creating the 'right' contextual circumstances remains crucially important, which includes willingness among all involved providers to bear shared financial and clinical responsibility for the entire care chain, regardless of where care is provided.

Neuropsychiatric symptoms in geriatric patients admitted to skilled nursing facilities in nursing homes for rehabilitation after stroke: a longitudinal multicenter study.

OBJECTIVE: To investigate the prevalence and course of neuropsychiatric symptoms (NPS) in geriatric patients admitted to skilled nursing facilities (SNFs) for rehabilitation after stroke. METHODS: This was a longitudinal multicenter study within 15 SNFs in the Netherlands. NPS were assessed in 145 patients with stroke through the Neuropsychiatric Inventory-Nursing Home version (NPI-NH) with measurements on admission and at discharge. The prevalence and course of NPS were described in terms of cumulative prevalence (symptoms either on admission or at discharge), conversion (only symptoms at discharge), remission (only symptoms on admission), and persistence (symptoms both on admission and at discharge) for patients who were discharged to an independent living situation within one year after admission and patients who had to stay in the SNF for long term care. RESULTS: Eighty percent had a first-ever stroke and 74% could be successfully discharged. Overall, the most common NPS were depression (33%), eating changes (18%), night-time disturbances (19%), anxiety (15%), irritability (12%), and disinhibition (12%). One year after admission, the patients who were still in the SNF showed significantly more hallucinations (p = 0.016), delusions (p = 0.016), agitation (p = 0.004), depression (p = 0.000), disinhibition (p = 0.004), irritability (p = 0.018), and night-time disturbances (p = 0.001) than those who had been discharged. DISCUSSION: The overall prevalence of NPS in this study was lower than reported by other studies in different settings. There was a high prevalence of NPS in patients that could not be successfully discharged. CONCLUSIONS: The findings suggest that NPS should be optimally treated to improve outcome of rehabilitation.

Determinants of rehabilitation outcome in geriatric patients admitted to skilled nursing facilities after stroke: a Dutch multi-centre cohort study.

OBJECTIVE: to identify important demographic, clinical and functional determinants of successful discharge of geriatric patients from skilled nursing facilities (SNFs), particularly the role of multi-morbidity. DESIGN: prospective cohort study with data collection at baseline and at discharge. SETTING: fifteen SNFs in the Netherlands. PARTICIPANTS: of 378 eligible patients, 186 were included. METHODS: multi-disciplinary teams recorded demographic and disease characteristics, as well as functional status, cognitive functioning and multi-morbidity on admission. The study outcomes were discharge to an independent living situation within 1 year of admission and functional status at discharge (Barthel index). RESULTS: of the included 186 patients, 175 were followed up. Of these patients, 123 (70%) were successfully discharged. High Berg Balance Scale (BBS) and Star Cancellation test (SCT) scores independently contributed to 48% of the variance of functional status at discharge, while low age, high BBS and SCT scores were independently related to successful discharge, explaining 33% of the variance. Multi-morbidity was not an independent determinant of rehabilitation outcome. CONCLUSION: geriatric patients admitted for 'low intensity' rehabilitation in SNFs after stroke appeared to have a fair prognosis for being successfully discharged. Postural control was an important determinant of both outcome measures.

To what extent can multimorbidity be viewed as a determinant of postural control in stroke patients?

OBJECTIVE: To investigate the determinants of postural imbalance after stroke in geriatric patients admitted for low-intensity rehabilitation in skilled nursing facilities (SNFs), particularly the role of multimorbidity. DESIGN: Cross-sectional study design. SETTING: Fifteen SNFs. PARTICIPANTS: All patients who were admitted for rehabilitation after stroke in one of the participating SNFs (N=378) were eligible. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The Berg Balance Scale (BBS) was selected as a measure of standing balance and the Functional Ambulation Categories (FAC) as a measure of walking balance. RESULTS: Multimorbidity was present in 34% of the patients. The patients with multimorbidity differed from the patients without multimorbidity with respect to age, proprioception, and vibration sense, but not for any of the cognitive tests, muscle strength, or sitting balance. Patients with multimorbidity had, on average, lower scores on both outcome measures. In linear regression analyses, both the BBS and FAC were best explained by multimorbidity, muscle strength, and the interaction between muscle strength and static sitting balance (overall explained variance 66% and 67%, respectively), while proprioception added only to the variance of the FAC. CONCLUSIONS: Multimorbidity was independently related to postural imbalance after stroke in patients admitted for rehabilitation in SNFs. Muscle strength and the interaction of muscle strength with static sitting balance were important determinants of both standing and walking balance, indicating these factors as essential targets for rehabilitation.

Is patient-grouping on basis of condition on admission indicative for discharge destination in geriatric stroke patients after rehabilitation in skilled nursing facilities? The results of a cluster analysis.

BACKGROUND: Geriatric stroke patients are generally frail, have an advanced age and co-morbidity. It is yet unclear whether specific groups of patients might benefit differently from structured multidisciplinary rehabilitation programs. Therefore, the aims of our study are 1) to determine relevant patient characteristics to distinguish groups of patients based on their admission scores in skilled nursing facilities (SNFs), and (2) to study the course of these particular patient-groups in relation to their discharge destination. METHODS: This is a longitudinal, multicenter, observational study. We collected data on patient characteristics, balance, walking ability, arm function, co-morbidity, activities of daily living (ADL), neuropsychiatric symptoms, and depressive complaints of 127 geriatric stroke patients admitted to skilled nursing facilities with specific units for geriatric rehabilitation after stroke. RESULTS: Cluster analyses revealed two groups: cluster 1 included patients in poor condition upon admission (n = 52), and cluster 2 included patients in fair/good condition upon admission (n = 75). Patients in both groups improved in balance, walking abilities, and arm function. Patients in cluster 1 also improved in ADL. Depressive complaints decreased significantly in patients in cluster 1 who were discharged to an independent- or assisted-living situation. Compared to 80% of the patients in cluster 2, a lower proportion (46%) of the patients in cluster 1 were discharged to an independent- or assisted-living situation. CONCLUSION: Stroke patients referred for rehabilitation to SNFs could be clustered on the basis of their condition upon admission. Although patients in poor condition on admission were more likely to be referred to a facility for long-term care, this was certainly not the case in all patients. Almost half of them could be discharged to an independent or assisted living situation, which implied that also in patients in poor condition on admission, discharge to an independent or assisted living situation was an attainable goal. It is important to put substantial effort into the rehabilitation of patients in poor condition at admission.

Comparison of eight prehospital stroke scales to detect intracranial large-vessel occlusion in suspected stroke (PRESTO): a prospective observational study.

BACKGROUND: Due to the time-sensitive effect of endovascular treatment, rapid prehospital identification of large-vessel occlusion in individuals with suspected stroke is essential to optimise outcome. Interhospital transfers are an important cause of delay of endovascular treatment. Prehospital stroke scales have been proposed to select patients with large-vessel occlusion for direct transport to an endovascular-capable intervention centre. We aimed to prospectively validate eight prehospital stroke scales in the field. METHODS: We did a multicentre, prospective, observational cohort study of adults with suspected stroke (aged ≥18 years) who were transported by ambulance to one of eight hospitals in southwest Netherlands. Suspected stroke was defined by a positive Face-Arm-Speech-Time (FAST) test. We included individuals with blood glucose of at least 2·5 mmol/L. People who presented more than 6 h after symptom onset were excluded from the analysis. After structured training, paramedics used a mobile app to assess items from eight prehospital stroke scales: Rapid Arterial oCclusion Evaluation (RACE), Los Angeles Motor Scale (LAMS), Cincinnati Stroke Triage Assessment Tool (C-STAT), Gaze-Face-Arm-Speech-Time (G-FAST), Prehospital Acute Stroke Severity (PASS), Cincinnati Prehospital Stroke Scale (CPSS), Conveniently-Grasped Field Assessment Stroke Triage (CG-FAST), and the FAST-PLUS (Face-Arm-Speech-Time plus severe arm or leg motor deficit) test. The primary outcome was the clinical diagnosis of ischaemic stroke with a proximal intracranial large-vessel occlusion in the anterior circulation (aLVO) on CT angiography. Baseline neuroimaging was centrally assessed by neuroradiologists to validate the true occlusion status. Prehospital stroke scale performance was expressed as the area under the receiver operating characteristic curve (AUC) and was compared with National Institutes of Health Stroke Scale (NIHSS) scores assessed by clinicians at the emergency department. This study was registered at the Netherlands Trial Register, NL7387. FINDINGS: Between Aug 13, 2018, and Sept 2, 2019, 1039 people (median age 72 years [IQR 61-81]) with suspected stroke were identified by paramedics, of whom 120 (12%) were diagnosed with aLVO. Of all prehospital stroke scales, the AUC for RACE was highest (0·83, 95% CI 0·79-0·86), followed by the AUC for G-FAST (0·80, 0·76-0·84), CG-FAST (0·80, 0·76-0·84), LAMS (0·79, 0·75-0·83), CPSS (0·79, 0·75-0·83), PASS (0·76, 0·72-0·80), C-STAT (0·75, 0·71-0·80), and FAST-PLUS (0·72, 0·67-0·76). The NIHSS as assessed by a clinician in the emergency department did somewhat better than the prehospital stroke scales with an AUC of 0·86 (95% CI 0·83-0·89). INTERPRETATION: Prehospital stroke scales detect aLVO with acceptable-to-good accuracy. RACE, G-FAST, and CG-FAST are the best performing prehospital stroke scales out of the eight scales tested and approach the performance of the clinician-assessed NIHSS. Further studies are needed to investigate whether use of these scales in regional transportation strategies can optimise outcomes of patients with ischaemic stroke. FUNDING: BeterKeten Collaboration and Theia Foundation (Zilveren Kruis).

Geriatric rehabilitation of stroke patients in nursing homes: a study protocol.

BACKGROUND: Geriatric patients are typically underrepresented in studies on the functional outcome of rehabilitation after stroke. Moreover, most geriatric stroke patients do probably not participate in intensive rehabilitation programs as offered by rehabilitation centers. As a result, very few studies have described the successfulness of geriatric stroke rehabilitation in nursing home patients, although it appears that the majority of these patients are being discharged back to the community, rather than being transferred to residential care. Nevertheless, factors associated with the successfulness of stroke rehabilitation in nursing homes or skilled nursing facilities are largely unknown. The primary goal of this study is, therefore, to assess the factors that uniquely contribute to the successfulness of rehabilitation in geriatric stroke patients that undergo rehabilitation in nursing homes. A secondary goal is to investigate whether these factors are similar to those associated with the outcome of stroke rehabilitation in the literature. METHODS/DESIGN: This study is part of the Geriatric Rehabilitation in AMPutation and Stroke (GRAMPS) study in the Netherlands. It is a longitudinal, observational, multicenter study in 15 nursing homes in the Southern part of the Netherlands that aims to include at least 200 patients. All participating nursing homes are selected based on the existence of a specialized rehabilitation unit and the provision of dedicated multidisciplinary care. Patient characteristics, disease characteristics, functional status, cognition, behavior, and caregiver information, are collected within two weeks after admission to the nursing home. The first follow-up is at discharge from the nursing home or one year after inclusion, and focuses on functional status and behavior. Successful rehabilitation is defined as discharge from the nursing home to an independent living situation within one year after admission. The second follow-up is three months after discharge in patients who rehabilitated successfully, and assesses functional status, behavior, and quality of life. All instruments used in this study have shown to be valid and reliable in rehabilitation research or are recommended by the Netherlands Heart Foundation guidelines for stroke rehabilitation.Data will be analyzed using SPSS 16.0. Besides descriptive analyses, both univariate and multivariate analyses will be performed with the purpose of identifying associated factors as well as their unique contribution to determining successful rehabilitation. DISCUSSION: This study will provide more information about geriatric stroke rehabilitation in Dutch nursing homes. To our knowledge, this is the first large study that focuses on the determinants of success of geriatric stroke rehabilitation in nursing home patients.

Challenging rehabilitation environment for older patients.

INTRODUCTION: After hospitalization, 11% of the older patients are referred to rehabilitation facilities. Nowadays, there is a trend to formalize the rehabilitation process for these patients in a Challenging Rehabilitation Environment (CRE). This concept involves the comprehensive organization of care, support and the environment on a rehabilitation ward. However, since literature on the principles of CRE is scarce, this review aimed to explore and describe the principles of CRE. METHODS: A search was made in PubMed for relevant literature concerning CRE. Then, articles were hand searched for relevant keywords (ie, task-oriented training, therapy intensity, patient-led therapy, group training), references were identified, and topics categorized. RESULTS: After evaluating 51 articles, 7 main topics of CRE were identified: 1) Therapy time; ie, the level of (physical) activity; the intensity of therapy and activity is related to rehabilitation outcomes, 2) group training; used to increase practice time and can be used to achieve multiple goals (eg, activities of daily living, mobility), 3) patient-regulated exercise; increases the level of self-management and practice time, 4) family participation; may lead to increased practice time and have a positive effect on rehabilitation outcomes, 5) task-oriented training; in addition to therapy, nurses can stimulate rehabilitants to perform meaningful tasks that improve functional outcomes, 6) enriched environment; this challenges rehabilitants to be active in social and physical activities, and 7) team dynamics; shared goals during rehabilitation and good communication in a transdisciplinary team improve the quality of rehabilitation. DISCUSSION: This is the first description of CRE based on literature; however, the included studies discussed rehabilitation mainly after stroke and for few other diagnostic groups. CONCLUSION: Seven main topics related to CRE were identified that may help patients to improve their rehabilitation outcomes. Further research on the concept and effectivity of CRE is necessary.

What is desirable care in the opinion of formal and informal caregivers in nursing-home care for patients with dementia?

Aim: To examine care characteristics related to desirable care as reported by formal and informal caregivers in Dutch Psycho-geriatric nursing homes for patients with dementia. Design: Qualitative exploratory study. Methods: The sample consisted of four nursing homes. In each home, semi-structured interviews were conducted with a manager, a quality advisor or head nurse, a daily care supervisor and an informal caregiver. The findings were analysed by labelling and coding the text fragments. Results: The 16 semi-structured interviews contained 60 discussion items. The 16 items that were shared by the four interviewee categories were clustered into the following six major themes: good quality of care; poor quality of care; elements of a vision; extra hands; bureaucracy; and formal caregivers.

Comorbidity and intercurrent diseases in geriatric stroke rehabilitation: a multicentre observational study in skilled nursing facilities.

BACKGROUND: Older patients often have multiple comorbidities and are susceptible to develop intercurrent diseases during rehabilitation. This study investigates intercurrent diseases and associated factors in patients undergoing geriatric stroke rehabilitation, focussing on pre-existing comorbid conditions, overall comorbidity and baseline functional status. MATERIALS AND METHODS: This multicentre prospective cohort study included 15 skilled nursing facilities. Data were collected at baseline and at discharge. The primary outcome measures were presence and number of intercurrent diseases. Furthermore, their impact on change in rehabilitation goals or length of stay was examined. Comorbidity was assessed with the Charlson index, and functional status with the Barthel index (BI). RESULTS: Of the 175 included patients, 51% developed an intercurrent disease. A lower baseline BI, a higher Charlson index, presence of diabetes mellitus (DM) and kidney disease were related to the occurrence of an intercurrent disease (p < 0.05). Moreover, a lower BI, a higher Charlson index, and particularly the presence of DM were independently associated. If both comorbidity and a lower baseline functional status were present, the odds ratio (95% CI) of developing intercurrent diseases was 6.70 [2.33-19.2], compared to 1.73 [0.52-5.72] (comorbidity only) and 1.62 [0.53-4.94] (only BI ≤ 14). CONCLUSIONS: On admission, functional impairments and comorbidity, particularly diabetes, independently contribute to developing intercurrent diseases during geriatric stroke rehabilitation. Therefore, routine evaluation of comorbidity integrated with functional status at the start of rehabilitation is essential to identify patients at risk. Finally, particular attention should be paid to patients with DM to prevent intercurrent diseases and support optimal functional recovery .

The Development of Integrated Stroke Care in the Netherlands a Benchmark Study.

INTRODUCTION: Integrated stroke care in the Netherlands is constantly changing to strive to better care for stroke patients. The aim of this study was to explore if and on what topics integrated stroke care has been improved in the past three years and if stroke services were further developed. METHODS: A web based self-assessment instrument, based on the validated Development Model for Integrated Care, was used to collect data. In total 53 coordinators of stroke services completed the questionnaire with 98 elements and four phases of development concerning the organisation of the stroke service. Data were collected in 2012 and 2015. Descriptive-comparative statistics were used to analyse the data. RESULTS: In 2012, stroke services on average had implemented 56 of the 89 elements of integrated care (range 15-88). In 2015 this was increased up to 70 elements on average (range 37-89). In total, stroke services showed development on all clusters of integrated care. In 2015, more stroke services were in further phases of development like in the consolidation and transformation phase and less were in the initiative and design phase. The results show large differences between individual stroke services. Priorities to further develop stroke services changed over the three years of data collection. CONCLUSIONS: Based on the assessment instrument, it was shown that stroke services in the Netherlands were further developed in terms of implemented elements of integrated care and their phase of development. This three year comparison showed unique first analyses over time of integrated stroke care in the Netherlands on a large scale. Interesting further questions are to research the outcomes of stroke care in relation to this development, and if benefits on patient level can be assessed.

Geriatric rehabilitation of lower limb amputees: a multicenter study.

PURPOSE: The aim of this study was to determine factors independently associated with successful rehabilitation of patients with lower limb amputation in skilled nursing facilities (SNFs). METHODS: All patients admitted to one of the 11 participating SNFs were eligible. Multidisciplinary teams collected the data. Successful rehabilitation was defined as discharge to an independent living situation within 1 year after admission. Functional status at discharge, as measured with the Barthel index (BI), was a secondary outcome. Multivariate regression analyses were used to assess the independent contribution of each determinant to the two outcome measures. RESULTS: Of 55 eligible patients, 48 were included. Mean age was 75 years. Sixty-five percent rehabilitated successfully. Multivariate analyses showed that presence of diabetes mellitus (DM) (OR 23.87, CI 2.26-252.47) and premorbid BI (OR 1.37, CI 1.10-1.70) were the most important determinants of successful rehabilitation, whereas 78% of the variance of discharge BI was explained by premorbid BI, BI on admission, and 1-leg balance. CONCLUSION: The presence of DM and high premorbid BI were associated with discharge to an independent living situation within 1 year after admission. Premorbid BI, admission BI, and 1-leg balance were independently associated to discharge BI.