1. Final Report The Stroke Rehabilitation Pilot Project of SEO This project was funded by the Ontario Ministry of Health, Long Term Care Cally Martin BScPT, MSc (Rehab) John Paterson BEd, MSc (Rehab)

2. Patient and Family Continuum of care The Ontario Stroke Strategy Stroke recognition Prevention Pre-hospital Emergency Acute REHAB Community Transition VISION To ensure that all Ontarians have access to the best possible quality stroke care, from prevention, through treatment and rehabilitation, to community re-integration.

3. NORTHUMBERLAND Southeastern Ontario Region Population 565,500 12,500 miles 2 20,000 km 2 H H H H H H HH H H H

4. The Discharge Link Project (DLP) Goal To investigate best practice related to stroke client transition from inpatient rehabilitation to the community by: enhancing therapy augmenting provider communication

5. The DLP Process Participants included: –Adults with new stroke –Recently discharged from inpatient rehab –Require home care –Going home or to residential setting Excluded: –Those going to LTC

6. The DLP Process The Enhanced Therapy (first 2 mths) –Pre-Discharge Link Meeting (OT to OT) –Post-Discharge OT & PSW meeting –Month 1  up to 2 extra visits/wk OT, PT and/or SLP  +5 hours extra PSW/wk –Month 2  up to 1 extra visit/wk OT, PT and/or SLP Allocation to group: ability of CCAC to provide enhanced service

7. The DLP Process Evaluation Function: –FIM (CIHI-NRS) at Rehab Admission and Discharge, 3, 6 & 12 mos after discharge RNL and Health Status at 3mos Client satisfaction survey Key Informant Interviews & focus groups CCAC workload Hospital readmissions Qualitative and quantitative analysis

8. DLP Distribution of Participants Total of 61 (24 U + 37 E) Groups were well matched Community Care Access Centre Usual care group Enhanced therapy group Totals Hastings and Prince Edward (HPE) 61218 Kingston, Frontenac, Lennox & Addington Counties (KFL&A) 81321 Lanark, Leeds and Grenville (LLG) 101222 Totals2437 61

9. DLP Severity of Stroke FRG = Functionally Related Group (at Admission) Based on ratio of motor and cognitive sub-scores on the FIM

10. Stroke FRGs Organized into Upper, Middle & Lower Bands

11. DLP: LOS and Wait Times U=106.5E=96.7 Total time post onset U=106.5 E=96.7

12. DLP: Community Provider Service (First 2 months, incl. 12 Link Meetings)

13. DLP: Functional Recovery intervention

14. DLP: Functional Recovery between Discharge and 3 mths

15. DLP: Change in Recovery

16. Regression Analysis The most significant predictors of the improved change in function were: 1. FIM score at Discharge p = 0.004* 2. Rehab Care Professional Visits p = 0.169# * significant at p<0.05 # evidence of contribution to the model

17. DLP: Hospital Readmissions U(24) E (37) Re-hospitalizations 11(46%) 9(24%) Total bed-days 133 73 Ave days per stay 8.3 6.1

18. DLP: Reasons for Readmissions Usual Care Group Fall, multiple fractures Fall, Pelvic fracture TIA, Seizure Pneumonia Infection Heart Condition Enhanced Care Group Knee replacement Hip replacement Bypass Surgery TIA, Seizure Pneumonia Infection Heart Condition

19. DLP: Hospital Readmissions - Costs

20. DLP: Cost Comparisons

21. “A cycle of discontinuity” “You get so used to working within a system that you … you forget that there might be something better out there...” “I finally get to do real OT!” Key informant interviews: Voices of Providers….

22. DLP: Other Findings U E Reintegration to Normal Living (3 mths, max 22) 15.714.5 (6 mths, max 22) 16.515.4 “How would you describe your own health?” poor 7% 0% fair 11%21% good 50%38% very good 32%41% excellent 0% 0%

23. DLP: Client Satisfaction (CCAC Survey Scores)

24. DLP: Key Informant Interview Process 14 people: clients, caregivers and providers 8 focus groups of 120 people

25. Key informant interviews: Voices of clients…. “I am totally overwhelmed”“Horrific” “Hell on earth” “It was hard. It was tough” “if spouses become therapists… it really degrades and demises the personal relationship.” “What do you do?”

26. DLP Interview Summary Chronic shortage of therapists Timely professional service has significant impact on recovery Travel costs for remote participants Flexibility needed in community therapy System barriers complicate the integration of care Need for stroke education in the community Role of PSWs in community Caregivers are overwhelmed

27. DLP Summary of Results Function & Access - Significantly improved change in function with enhanced professional therapy in first 2 months - Community service at transition point means faster functional recovery Satisfaction: Patient, Caregiver & Provider - time for collaboration important -caregivers are overwhelmed - System barriers frustrate providers Utilization - enhanced therapy: half the readmissions to hospital -models of community care differ widely

28. DLP Recommendations 1. Provide enhanced & timely professional therapy for stroke clients 2. Consider priority setting for those recovering from new stroke 3. Increase system responsiveness and flexibility 4. Establish a formal process for coordination of care 5. Promote models of care that promote client recovery

29. DLP Recommendations, p2 6. Investigate strategies to recruit and retain professional services and promote stable provider workforce 7. Provide stroke rehab education to CCAC, professional staff and PSWs 8. Explore role of OT, PT communication assistants 9. Support caregivers 10. Regional planning

30. DLP Sustainability Cost Effectiveness –Enhanced and timely therapy increases function and may decrease utilization –Client selection important –Regional planning mechanisms to maximize service –Resourced transition planning has long term benefits

31. DLP: Transferability Results are transferable to people who… live anywhere, regardless of where have a new disability and can’t access service have the potential to recover are in LTC?

32. Thank you! The Ontario Ministry of Health, Long-Term Care for funding the project The Rehab subcommittee CCACs and Hospitals of SEO Care providers Clients, Caregivers/Family