Of course, the first priority after stroke is stabilizing the patient. Once a hospitalized survivor is medically stable, they may be moved to inpatient rehab. Inpatient rehab is sometimes referred to as acute rehab and requires at least three hours of therapy a day.
The goal of inpatient rehabilitation is to return patients safely to their home environment.(Tyranny of low expectations in full display here.) The average stay is 15 days, although some patients may stay less and others may stay longer. Patients not able to meet the requirements of inpatient rehab may be discharged to a skilled nursing facility. (See Making the Best Decisions at Discharge and What to Expect from Rehab for more on inpatient rehab and skilled nursing facilities.) After leaving inpatient rehab, survivors are typically discharged home.
“Once home, survivors may need ongoing therapy to continue to build their strength and return to the activities they pursued before the stroke,” said physical therapist Kim Brennan, administrative director of outpatient therapy and specialized services at Shirley Ryan AbilityLab in Chicago. In that case, survivors may be transitioned to outpatient rehab, either provided in an outpatient clinic or at home through a home healthcare agency. In outpatient therapy, survivors go into a rehab facility, which distinguishes it from home-based therapy. Prescriptions and insurance vary, but outpatient therapy is typically two or three hours, once or twice a week.
“Whether a patient is referred to inpatient or outpatient therapy depends on the level of medical care required,” said Brennan. “When a patient’s medical status can be managed and monitored without IVs, nursing care and the like, then the patient can be considered for outpatient rehabilitation.”
Outpatient or Home-based Therapy?
The decision of whether to use outpatient or home-based therapy depends on the survivor’s abilities. “If the patient demonstrates difficulty getting in and out of the home, he or she would be a better candidate for home health therapy until he or she is strong enough to regularly attend therapy in an outpatient clinic,” Brennan said. “Stairs can often be a barrier to transitioning out of the house for appointments or community events, and having a therapist come to the house to practice the stairs and negotiate the rest of the home environment can be helpful. Inpatient rehabilitation simulates these activities, but everyone’s home environment is unique and presents different challenges after stroke.”
Home therapy is not considered to be part of outpatient therapy; it is a separate level of care. Home health therapy is often recommended when a patient is homebound and may require continued nursing support for issues such as wound care, blood draws, etc., in addition to therapy care.
Bridging Levels of Care
At Shirley Ryan AbilityLab, they offer a program called Day Rehabilitation, which is a bridge from acute inpatient rehabilitation to outpatient therapy. “Day Rehabilitation provides patients with three-to-six hours of therapy three-to-five days per week with the primary goal of community reintegration,” Brennan said. “Upon discharge from this program, outpatient therapy may be considered if ongoing therapy is required.” Not all rehab hospitals have a program like this.
Types of Therapies in Outpatient Facilities
Outpatient therapy may consist of occupational, physical and speech therapy. Recreational, art, and music therapy may also be offered during inpatient rehab or at a skilled nursing facility. Brennan says that they collaborate closely with their fitness center so that patients have the option to pursue a personalized exercise program with an exercise physiologist upon discharge.
Getting the Most Out of an Outpatient Therapy Rx
Brennan offered a few recommendations patients should consider for outpatient care:
• Of course, picking the right facility is key. In therapy, one size does not fit all. The most successful rehab is provided by a team of therapists who discuss the various needs of individual patients. Patients and their families need to be included as members of that team. So, a good question for stroke families to ask is “are we involved in patient-care plan discussions?.”
• Finding the best providers for your condition is key, so it is important to call ahead to make sure the clinic has the specialists who fit your diagnosis. “What kind of therapy do you offer?”
• It is important to get one-on-one quality time with your therapist so that you can get the most out of each session and make quicker gains. Although group therapy can be beneficial in some instances, avoid situations where survivors are given only or primarily group therapy. Ask: “How much individual therapy will my survivor receive?”
• Patient-established goals are important. They should be set at the beginning of care and monitored regularly to ensure progress is being made. “Are you going to ask my father what his goals are and design his rehab program around those goals? How will they be monitored?”
• Communication is key! Open lines of communication with your provider around progress, goals and any barriers that may arise are important to ensure that you achieve the best outcome.
Location shouldn’t be the only consideration
In most areas, there are more outpatient facilities than inpatient, and often stroke families chose a facility that is close to home. Brennan cautions that geographic location may not be the most relevant criterion: “It is very important to find the clinic that is best positioned to promote the quickest recovery and best outcome for the patient, regardless of location,” she said.
The good news is that despite the inherent complexity of the stroke recovery process, rehab works, and families can expect to see improvement as their survivor recovers and orients to a new self. Carolee J. Winstein, Ph.D., P.T., the lead author of the American Stroke Association’s Guidelines for Stroke Rehabilitation and Recovery for Adults remains optimistic for stroke survivors in rehabilitation: “I think it’s important for family members to expect some recovery. It may not be full recovery, back to the way the person was before, but it is not a death sentence. I think we have to say there is definitely hope. If you made it through the acute phase, there is definitely hope.”
The End of Medicare Outpatient Therapy Caps
The two-year budget deal, approved by the House and the Senate and signed into law in February, included provisions that expand access for telestroke and cardiac rehabilitation services, remove restrictions on Medicare outpatient therapy caps and help improve the health of patients with cardiovascular disease.
Past caps on therapy have seriously limited treatment options for millions of Americans. As a result of the budget deal, Medicare patients will have access to medically necessary rehabilitation services without the $2,000 limit that was in place. Brennan cautioned that this repeal does not throw open the doors of rehab facilities for unlimited rehab for survivors. “Although the cap on Medicare therapy has been repealed, established Medicare guidelines are still in place,” she said. “This means there are still limitations to what Medicare will cover, from a medical necessity standpoint.”(So getting you 100% recovered is not a medical necessity. Hope you are OK with that.)
This article is reprinted from the American Stroke Association's Stroke Connection digital magazine—Summer 2018 issue. To subscribe to Stroke Connection quarterly visit strokeconnection.strokeassociation.