1. Vertical Planning for Stroke Care in PM&R Randie M. Black-Schaffer, M.D. Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston MA

2. 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/disorderswww.ninds.nih.gov/disorders /stroke/stroke_rehabilitation

3. 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

4. Vertical Planning Concept StrokeSpine Practice Legislation Advocacy Education Communications

5. 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

6. 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.

7. 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

8. VP Plan-Practice & Advocacy 1.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.

9. VP Plan - Education 1. 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

10. VP Plan-Communication 1. 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

11. Innovative Practice models for PM&R in stroke care Skilled Nursing Facility Stroke Rehabilitation Long-Term Outpatient follow-up Consultation in the neuro ICU

12. 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

13. 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

14. Challenges for PM&R in SNF Rehab Consultant vs. attending Ancillary services Nursing, therapy staffing and resources Team process – Assessment – MDS – Care plan

15. 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

16. 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?

17. 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

18. Thank you! rblackschaffer@partners.org Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston MA