Rehab Med Advances

NewYork-Presbyterian

Advances in Rehabilitation Medicine

Stroke Recovery: Factors Determining Post-Discharge Destinations

It is estimated that two-thirds of the more than 800,000 individuals in the United States who have a stroke will require rehabilitation services. Post-acute care plays a critical role in a patient’s recovery, and yet the criteria influencing the level of care is subjective and not well established. Presently post-acute rehabilitative care in the U.S. is generally provided in either an inpatient rehabilitation facility, which provides a more intensive level of therapy, or a skilled nursing facility. The lack of a well-validated decision support tool adds to variations in practice.

image of Dr. Joel Stein

Dr. Joel Stein

On behalf of the Northeast Cerebrovascular Consortium Stroke Rehabilitation and Recovery Delphi Study Group, Joel Stein, MD, Physiatrist-in-Chief, NewYork-Presbyterian Hospital, led a study to delineate key factors influencing the selection of post-acute level of care for these patients. Their investigation employed a four-round Delphi process to refine a list of factors by an invited panel of 32 experts from throughout the United States. These included physicians, physical therapists, occupational therapists, speech-language pathologists, nurses, stroke survivors, administrators, policy experts, and representatives from insurance companies.

To the researchers’ knowledge, this is the first study to use the Delphi methodology to examine post-stroke clinical decision-making and to assemble a list of factors as a first step to develop, test, and validate a clinical decision support tool.

Panelists participated in an initial brainstorming session to identify factors that should be considered in determining post-acute discharge level of care. This initial meeting generated 207 factors grouped into several categories and ultimately consolidated to 15 factors for consideration. In the final round, the following 9 factors were rated with Likert scores ranging from 5 (most important) to 1 (not important) with percentage of panelists who provided a rating of 4 or above:

  • Likelihood to benefit from an active rehabilitation program (97 percent)
  • Need for clinicians with specialized rehabilitation skills (94 percent)
  • Need for active and ongoing medical management and monitoring (84 percent)
  • Ability to tolerate an active rehabilitation program (74 percent)
  • Need for caregiver training to return to the community (48 percent)
  • Family/caregiver support (39 percent)
  • Likelihood to return to community/home (39 percent)
  • Ability to return to physical home environment (32 percent)
  • Premorbid dementia (16 percent)

Study findings, which were published in the March 2022 issue of Stroke, provide a novel identification and ranking of clinical and environmental factors deemed significant in determining the most fitting level of post-acute care for stroke survivors. The authors plan to  validate these factors in a clinical sample and create a decision support tool and verify their utility in clinical care.

Read More

Which Road to Recovery? Factors Influencing Post-acute Stroke Discharge Destinations: A Delphi Study. Stein J, Rodstein BM, Levine SR, Cheung K, Sicklick A, Silver B, Hedeman R, Egan A, Borg-Jensen P, Magdon-Ismail Z; Northeast Cerebrovascular Consortium Stroke Rehabilitation and Recovery Delphi Study Group. Stroke. 2022 Mar;53(3):947-955.

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Dr. Joel Stein

NewYork-Presbyterian

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