Developing and evaluating an integrated rehabilitative model of care for stroke patients in the home and community care sector

Background: Stroke is a leading cause of disability and the third leading cause of mortality in Canada. Access to evidence-based rehabilitative care can reduce the risk of disability and improve health outcomes of stroke survivors. Up until recently, stroke survivors in many health regions in Canada did not have access to intensive and timely community-based rehabilitation which followed the recommended Canadian Stroke best practice guidelines. As a result, stroke survivors suffered negative health outcomes and had suboptimal experiences as they transitioned to home from a hospital or a rehabilitation centre. The Waterloo Wellington health region of Ontario re-designed its stroke care system across the continuum of care, including implementation of an integrated community stroke rehabilitation pathway that is in alignment with the Canadian stroke best practices. Significant investments in resources have been made to reorganize and integrate the stroke care system with the intention of improving patient outcomes and patient experience. This study aimed to evaluate the newly implemented model of care by measuring patient’s health outcomes as well as patient experience. The study also compared the psychometric properties of the interResident Assessment Instrument-Home Care (interRAI HC) with other commonly used assessment tools in the stroke rehabilitation population. \n \nResearch Objectives: This research study consisted of two primary research questions and a third secondary question. The first research objective was to answer the question, “What are the functional and depression related outcomes of stroke survivors that received stroke rehabilitation through the community stroke rehabilitation model of care? \n \nThe second research objective is to answer the question, “What is the experience of stroke survivors that received care through the community stroke rehabilitation model of care?” \n \nThe third research objective aims to answer the question, “How do the psychometric properties of responsiveness and construct validity of specific scales embedded in interRAI HC instrument compare with those of the Barthel Index (BI) and Reintegration to Normal Living Index (RNLI) instruments?” \n \nMethods: To evaluate functional and depression related outcomes, an observational study with a pre-post design was used. Secondary home care data were extracted on patient assessments during April 2014 to April 2017 using the interRAI HC, BI and RNLI instruments. Outcomes were measured for the ADL and DRS scales. A control group was formed using data from the Canadian Institute for Health Information (CIHI); this group included stroke survivors who received traditional rehabilitative care or no care post hospital discharge in the community elsewhere in Ontario during the same period. Four regression models were created to explore associations between having functional or depression related impairment and the treatment assignment (treatment vs control group). Models were adjusted using a propensity score variable to control for treatment selection bias. \n \nTo evaluate patient experience, a Patient Experience Survey for Community-based Rehabilitation (PESCR) instrument was developed for this project using a Program Logic Model (PLM) and also through consultations with subject matter experts and stroke survivors. The PESCR was administered in a home care setting to stroke survivors who completed the rehabilitation program, at the 3 months follow up home visit by a community care coordinator. Participants were asked to provide feedback on: 1) patient experience; 2) transitional care; 3) timeliness of access to care; 4) integrated care; and 5) returning to normal activities. Internal consistency reliability was measured using Cronbach’s alpha coefficient. Construct validity was assessed using the correlation of total scores with a global question. Thematic content analysis was used to review the open-ended responses on the survey. \n \nTo answer the third research question, responsiveness statistics (standardized response mean and effect size) were used to compare the interRAI HC ADL Long Form and DRS with the BI and RNLI respectively. Construct validity was assessed by the correlation between the ADL Long Form and the BI as well as the correlation between the DRS and the RNLI. \n \nResults \nDuring the period of 2014 and 2017, 479 stroke survivors were placed onto the community stroke rehabilitation pathway for approximately 12 weeks in the Waterloo Wellington health region. Each stroke survivor received an average of 30.5 rehabilitation home visits with an average time of 56 minutes per visit. The mean age of participants was 77.9 (9.5 SD) and 51.2% were females. After adjusting for baseline characteristics and treatment selection bias, participants in the treatment group were three (2.99) times more likely to be independent in ADLs than those in the control group at the 3 months follow up (Adjusted OR = 2.99, 95% CI 1.53 – 5.86, p < 0.01). Participants in the treatment group were 3.8 times more likely to have no difficulty in IADL activities than those in the control group at the 3 months follow up (Adjusted OR = 3.83, 95% CI 1.77 – 8.25, p < 0.001). There was no statistically significant association found between treatment assignment and depression (Adjusted OR = 0.81, 95% CI 0.47 – 1.38, p > 0.05). \n \nFour hundred and four (84.3%) individuals that received care through the Waterloo Wellington’s stroke rehabilitation model of care were asked to complete the patient experience survey. Of these, 134 (33.1%) participants responded including 112 (83.5%) stroke survivors and 22 (16.4%) family members/care givers. Of those that completed the survey, 122 (91.0%) participants were satisfied with the care they received in the community. Based on the open-ended responses, many participants felt that the therapy should have continued beyond the 3-month period post hospital discharge. The responses also suggested that clients and families preferred a longer but less intense physical therapy. Some respondents also felt overwhelmed when the community rehabilitation was initiated within 48 hours of hospital discharge. Some respondents felt that community rehabilitation started too early as stroke survivors and families needed time for adjustment as they transitioned back home. \n \nThe interRAI HC’s ADL Long Form scale and BI were highly correlated and seem to be evaluating their intended constructs. However, the ADL Long Form was not as responsive as the BI particularly in the subpopulation of stroke population with no or minimal levels of impairment in conducting ADLs. The DRS and RNLI were not correlated with each other and appear to measure different aspects of an individual’s psychosocial outcomes. \n \nThe responsiveness results of our study suggest that the ADL and DRS scales from the interRAI HC instrument perform well in subpopulations with significant impairment, such as those who scored high on ADL scales, but these scales have less discriminatory power among those with less physical or psychosocial impairment, such as those with scores of zero on ADL or DRS scales. \n \nConclusion: Our study adds to the body of evidence suggesting that a community-based rehabilitation program that is timely, well-coordinated and follows the recommended intensity (2-3 rehabilitation visits per week per discipline for up to 12 weeks), can achieve significant improvements in functional outcomes among a large proportion of stroke survivors who are trying to reintegrate back in the community. \n \nThe participants had a positive experience overall as well as for specific aspects of care delivery. The lower scores in returning to normal activities suggest that some participants might continue to have unmet needs of functional independence. \n \nThe interRAIHC’s ADL Long form and the DRS are valuable scales that are already part of the existing bundle of standardized geriatric assessment in the home and community care. Information collected using these assessments can be useful in the stroke rehabilitation population. \n \nSignificance and Knowledge Translation: This study helps establish evidence for whether investments made in stroke community rehabilitative care in the Waterloo Wellington community are resulting in intended patient outcomes and improved patient experience. Results from this study highlight improvement opportunities for the existing model. It is hoped that this study also helps health planners and service providers to implement similar service delivery models in other regions. \n

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