1. Stroke Pathways Taskforce Joseph Burris, MD Director, Stroke Rehabilitation Missouri Stroke Program/Rusk Rehabilitation Center University of Missouri Columbia, MO

2. Disclosures Allergan Bureau speaker/honoraria Research grants Merz Research grant

3. AAPM&R Stroke Pathways Task Force Joseph Burris, MD – University of Missouri Randie Black-Schaffer, MD, MA – Spaulding Rehabilitation/Harvard Richard Harvey, MD – Rehabilitation Institute Chicago/Northwestern Vu Nguyen, MD – Carolinas Rehabilitation Brad Steinle, MD – Saint Luke’s Healthsystem, Kansas City, MO Richard Zorowitz, MD – Medstar/National Rehabilitation Hospital

4. Acute Hospitalization AAPM&R -- Management of Stroke Rehabilitation  Physiatry/rehabilitation physician consultation during acute hospitalization for patients with stroke rehabilitation needs, evaluation and management planning: o NIHSS review  Categorize recovery estimation  <7 anticipate good recovery  7-16 variable recovery  > 16 anticipate poor recovery o Stroke recurrence risk factors o Secondary stroke prophylaxis o Medical comorbidities and effects on post acute care needs o DVT prophylaxis o Cognition/communication o Dysphagia o Nutrition o Mobility/self care o Bowel/bladder function o Skin integrity o Caregiver availability o Patient/caregiver education o Depression/mental health screen o Spasticity o Durable medical equipment/orthotic needs  Recommendation regarding transition to appropriate level of post acute care and follow up with physiatry/rehabilitation physician for future stroke rehabilitation needs  Physiatry/rehabilitation physician consultation during acute hospitalization for patients with stroke rehabilitation needs, evaluation and management planning: o NIHSS review  Categorize recovery estimation  <7 anticipate good recovery  7-16 variable recovery  > 16 anticipate poor recovery o Stroke recurrence risk factors o Secondary stroke prophylaxis o Medical comorbidities and effects on post acute care needs o DVT prophylaxis o Cognition/communication o Dysphagia o Nutrition o Mobility/self care o Bowel/bladder function o Skin integrity o Caregiver availability o Patient/caregiver education o Depression/mental health screen o Spasticity o Durable medical equipment/orthotic needs  Recommendation regarding transition to appropriate level of post acute care and follow up with physiatry/rehabilitation physician for future stroke rehabilitation needs Transition to appropriate level of post acute care

5. AAPM&R -- Management of Stroke Rehabilitation Post Acute Institutional Based AAPM&R -- Management of Stroke Rehabilitation Post Acute Institutional Based o Inpatient Rehabilitation Facility (IRF):  Coordinated, interdisciplinary rehabilitation team with expertise in stroke rehabilitation, including: physiatrist/rehabilitation physician; physical, occupational, and speech therapy; psychology; rehabilitation nursing; case manager/social worker. May also include recreational therapy, vocational rehabilitation, neuropsychology  Requires at least 2 of 3: PT/OT/ST  Sufficient medical stability to perform at least 3 hours of therapy at least 5 days per week or 15 hours of therapy over 7 days per week under special circumstances (e.g. dialysis)  Physiatrist/rehabilitation physician oversight 3-7 days per week for evaluation/intervention of medical/rehabilitation management issues  Including items highlighted o Inpatient Rehabilitation Facility (IRF):  Coordinated, interdisciplinary rehabilitation team with expertise in stroke rehabilitation, including: physiatrist/rehabilitation physician; physical, occupational, and speech therapy; psychology; rehabilitation nursing; case manager/social worker. May also include recreational therapy, vocational rehabilitation, neuropsychology  Requires at least 2 of 3: PT/OT/ST  Sufficient medical stability to perform at least 3 hours of therapy at least 5 days per week or 15 hours of therapy over 7 days per week under special circumstances (e.g. dialysis)  Physiatrist/rehabilitation physician oversight 3-7 days per week for evaluation/intervention of medical/rehabilitation management issues  Including items highlighted Skilled Nursing Facility (SNF): Multidisciplinary rehabilitation team, should/may include: physical, occupational, speech,recreational therapy, psychology, nursing, case manager/social worker Ability to perform at least 1- 3 hours of therapy 5 days per week Physiatry/rehabilitation attending/consultant for recommendations specific to stroke rehabilitation needs Including items highlighted Skilled Nursing Facility (SNF): Multidisciplinary rehabilitation team, should/may include: physical, occupational, speech,recreational therapy, psychology, nursing, case manager/social worker Ability to perform at least 1- 3 hours of therapy 5 days per week Physiatry/rehabilitation attending/consultant for recommendations specific to stroke rehabilitation needs Including items highlighted Long Term Care Hospital(LTCH): Medical treatment issues supersede rehabilitation needs at another level of post acute care 3 day ICU stay during acute hospitalization required Physiatry consultant for recommendations specific to stroke rehabilitation needs: Including items highlighted Long Term Care Hospital(LTCH): Medical treatment issues supersede rehabilitation needs at another level of post acute care 3 day ICU stay during acute hospitalization required Physiatry consultant for recommendations specific to stroke rehabilitation needs: Including items highlighted Nursing facility: Patient/caregivers unable to meet needs for community discharge For acute stroke, IRF/SNF benefits may be available Formal/restorative therapy needs, as indicated Including items highlighted ** Nursing facility: Patient/caregivers unable to meet needs for community discharge For acute stroke, IRF/SNF benefits may be available Formal/restorative therapy needs, as indicated Including items highlighted ** The patient with stroke rehabilitation needs will best benefit from evaluation and management in the following post acute care setting(s): Recommendation for transition to appropriate level of post acute care and follow up with physiatry/rehabilitation physician for stroke rehabilitation needs, as indicated  Goal of community discharge  Education and training for patient/caregivers**  Cognition/communication**  Bowel/bladder function*  Skin integrity*  Mobility/self care (ADL)**  Medical care adjustments for comorbid conditions**  Dysphagia/nutrition needs for elevated malnutrition/dehydration risk**  Pain management**  Spasticity/hypertonicity management**  Adjustment and mood disorders, including psychology consultation**  Durable medical equipment**  Orthotic and assistive devices**  Assessment of post acute rehabilitation community and financial resources**  Consultation and follow up care with primary physician, and neurology/neurosurgery/other specialties, as indicated**  Goal of community discharge  Education and training for patient/caregivers**  Cognition/communication**  Bowel/bladder function*  Skin integrity*  Mobility/self care (ADL)**  Medical care adjustments for comorbid conditions**  Dysphagia/nutrition needs for elevated malnutrition/dehydration risk**  Pain management**  Spasticity/hypertonicity management**  Adjustment and mood disorders, including psychology consultation**  Durable medical equipment**  Orthotic and assistive devices**  Assessment of post acute rehabilitation community and financial resources**  Consultation and follow up care with primary physician, and neurology/neurosurgery/other specialties, as indicated**

6. AAPM&R -- Management of Stroke Rehabilitation Post Acute Community Based AAPM&R -- Management of Stroke Rehabilitation Post Acute Community Based Home Health: Patient will be considered “homebound” Patient/family will benefit from interventions specific to their home environment Inability to arrange logistics for attendance in an outpatient treatment program due to patient tolerance or program availability Physical, occupational, and speech therapy, social worker, as indicated Nursing/aide, as indicated Including items * Home Health: Patient will be considered “homebound” Patient/family will benefit from interventions specific to their home environment Inability to arrange logistics for attendance in an outpatient treatment program due to patient tolerance or program availability Physical, occupational, and speech therapy, social worker, as indicated Nursing/aide, as indicated Including items * Outpatient Therapy:  Physical, occupational, and speech therapy as indicated  Interdisciplinary outpatient programs, as available/indicated  (Rehabilitation) Psychology, as indicated  Neuropsychologic testing, as indicated  Vocational rehabilitation, as indicated  Driving evaluation,as indicated  Including items * Outpatient Therapy:  Physical, occupational, and speech therapy as indicated  Interdisciplinary outpatient programs, as available/indicated  (Rehabilitation) Psychology, as indicated  Neuropsychologic testing, as indicated  Vocational rehabilitation, as indicated  Driving evaluation,as indicated  Including items * o Hospice and Palliative Care:  Poor prognosis of recovery (<6months life expectancy)  Goal of appropriate end of life care  Including items highlighted o Hospice and Palliative Care:  Poor prognosis of recovery (<6months life expectancy)  Goal of appropriate end of life care  Including items highlighted The patient with stroke rehabilitation needs will best benefit from evaluation and management in the following post acute care setting: Recommendation for transition to appropriate level of post acute care and follow up with physiatry/rehabilitation physician for stroke rehabilitation needs, as indicated Education for patient/caregivers** Cognition/communication** Bowel/bladder function* Skin integrity* Mobility/self care (ADL)** Medical care adjustments for comorbid conditions** Dysphagia/nutrition needs for elevated malnutrition/dehydration risk** Pain management** Spasticity/hypertonicity management** Adjustment and mood disorders, including psychology consultation** Durable medical equipment** Orthotic and assistive devices** Assessment of post acute rehabilitation community and financial resources** Consultation and follow up care with primary physician, and neurology/neurosurgery/other specialties, as indicated** Education for patient/caregivers** Cognition/communication** Bowel/bladder function* Skin integrity* Mobility/self care (ADL)** Medical care adjustments for comorbid conditions** Dysphagia/nutrition needs for elevated malnutrition/dehydration risk** Pain management** Spasticity/hypertonicity management** Adjustment and mood disorders, including psychology consultation** Durable medical equipment** Orthotic and assistive devices** Assessment of post acute rehabilitation community and financial resources** Consultation and follow up care with primary physician, and neurology/neurosurgery/other specialties, as indicated**

7. AAPM&R -- Management of Stroke Rehabilitation Acute Hospitalization AAPM&R -- Management of Stroke Rehabilitation Acute Hospitalization  Physiatry/rehabilitation physician consultation during acute hospitalization for patients with stroke rehabilitation needs, evaluation and management planning: o NIHSS review  Categorize recovery estimation  <7 anticipate good recovery  7-16 variable recovery  > 16 anticipate poor recovery o Stroke recurrence risk factors o Secondary stroke prophylaxis o Medical comorbidities and effects on post acute care needs o DVT prophylaxis o Cognition/communication o Dysphagia o Nutrition o Mobility/self care o Bowel/bladder function o Skin integrity o Caregiver availability o Patient/caregiver education o Depression/mental health screen o Spasticity o Durable medical equipment/orthotic needs  Recommendation regarding transition to appropriate level of post acute care and follow up with physiatry/rehabilitation physician for future stroke rehabilitation needs  Physiatry/rehabilitation physician consultation during acute hospitalization for patients with stroke rehabilitation needs, evaluation and management planning: o NIHSS review  Categorize recovery estimation  <7 anticipate good recovery  7-16 variable recovery  > 16 anticipate poor recovery o Stroke recurrence risk factors o Secondary stroke prophylaxis o Medical comorbidities and effects on post acute care needs o DVT prophylaxis o Cognition/communication o Dysphagia o Nutrition o Mobility/self care o Bowel/bladder function o Skin integrity o Caregiver availability o Patient/caregiver education o Depression/mental health screen o Spasticity o Durable medical equipment/orthotic needs  Recommendation regarding transition to appropriate level of post acute care and follow up with physiatry/rehabilitation physician for future stroke rehabilitation needs Transition to appropriate level of post acute care

8. Needs to be considered by Physiatry/Rehabilitation Physician -Community discharge -Cognition/communication -Bowel/bladder management -Skin integrity -Mobility/self care -Medication management -Dysphagia/nutrition -Pain management -Spasticity management -Adjustment/mood disorders -DME, orthotic/assistive devices -Funding for care needs -Communication with other treating physicians Skilled Nursing Facility Skilled nursing and/or therapy PT,OT, SLP,TR, nursing, case management 1-3 hrs of therapy 5 days/wk PM&R/rehabilitation physician for stroke rehab needs Long Term Nursing Facility Caregivers unable to meet patient’s needs In community Custodial care Formal or restorative therapy as indicated Long Term Acute Care Medical needs paramount 3 day ICU stay at Acute hospital required PM&R/rehabilitation physician for stroke rehab needs Inpatient Rehabilitation Facility Rehabilitation needs paramount - 3hrs/day 5 days/wk PT/OT/SLP Interdisciplinary team with expertise in stroke rehab -PT,OT,SLP,TR, psychology, case management, nursing PM&R/rehabilitation physician visits 3-7x/wk

9. Needs to be considered by PM&R/rehabilitation physician --Cognition/communication -Bowel/bladder management -Skin integrity -Mobility/Self Care -Stroke rehab medication management -Dysphagia/nutrition -Pain management -Spasticity management -Adjustment and mood disorders -DME, orthotic/assistive devices -Funding for care needs -Communication with other treating physicians Home Health Patient is homebound, unable to travel to outpatient site. PT, OT, SLP, HHA as needed 1-3X/wk. Skilled nursing required. Outpatient Therapy PT,OT,SLP 1-4X/wk Psychology/Neuropsycholog y Vocational Rehabilitation Driving evaluation Hospice and Palliative care Poor prognosis <6 months End of life care AAPM&R – Management of Stroke Rehabilitation Community Based Post-Acute Care