THE REHABILITATION PROGRAM
Annotation I. Does the Patient Need Rehabilitation Intervention?
7.1 Determine Rehabilitation Needs
RECOMMENDATIONS
1. Once the patient is medically stable, the primary physician should consult with rehabilitation services (i.e., physical therapy, occupational therapy, speech and language pathology, kinesiotherapy, and Physical Medicine) to assess the patient’s impairments, as well as activity and participation deficiencies to establish the patient's rehabilitation needs and goals.
2. A multidisciplinary assessment should be undertaken and documented for all patients. [A]
3. Patients with no residual disability post acute stroke who do not need rehabilitation services may be discharged back to home.
4. Strongly recommend that patients with mild to moderate disability in need of rehabilitation services have access to a setting with a coordinated and organized rehabilitation care team that is experienced in providing stroke services. [A]
5. Post-acute stroke care should be delivered in a setting where rehabilitation care is formally coordinated and organized.
6. If an organized rehabilitation team is not available in the facility, patients with moderate or severe disability should be offered a referral to a facility with such a team. Alternately, a physician or rehabilitation specialist with some experience in stroke should be involved in the patient's care.
7. Post-acute stroke care should be delivered by a variety of treatment disciplines experienced in providing post-stroke care to ensure consistency and reduce the risk of complications.
8. The multidisciplinary team may consist of a physician, nurse, physical therapist, occupational therapist, kinesiotherapist, speech and language pathologist, psychologist, recreational therapist, social worker, patient, and family/caregivers.
9. Patients who are severely disabled and for whom prognosis for recovery is poor may not benefit from rehabilitation services and may be discharged to home or nursing home in coordination with family/care giver.
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Summary Guideline Management of Stroke Rehabilitation
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Annotation J. Are Early Supportive Discharge Rehabilitation Services Appropriate?
7.2 Determine Rehabilitation Setting
RECOMMENDATIONS
1. The medical team, including the patient and family, must analyze the patient’s medical and functional status, as well as expected prognosis to establish the most appropriate rehabilitation setting. [I]
2. The severity of the patient’s impairment, the rehabilitation needs, the availability of family/social support and resources, the patient/family goals and preferences, and the availability of community resources will determine the optimal environment for care. [I]
3. Where comprehensive interdisciplinary community rehabilitation services and caregiver support services are available, early supported discharge services may be provided for people with mild to moderate disability. [B]
4. Recommend that patients remain in an inpatient setting for their rehabilitation care if they are in need of daily professional nursing services, intensive physician care, and/or multiple therapeutic interventions.
5. There is insufficient evidence to recommend the superiority of one type of rehabilitation setting over another.
6. Patients should receive as much therapy as they are able to tolerate in order to adapt, recover, and/or reestablish their premorbid or optimal level of functional independence. [B]
Annotation K. Discharge Patient from Rehabilitation
See Section 8 –Discharge
Annotation L. Arrange For Medical Follow-Up
See Section 8.1 – Follow-up
Annotation M. Post-Stroke Patient in Inpatient Rehabilitation
Inpatient rehabilitation is defined as rehabilitation performed during an inpatient stay in a free-standing rehabilitation hospital or a rehabilitation unit of an acute care hospital. The term “inpatient” is also used to refer generically to programs where the patient is in residence during treatment, whether in an acute care hospital, a rehabilitation hospital, or a nursing facility.
Patients typically require continued inpatient services if they have significant functional deficits and medical and/or nursing needs that requires close medical supervision and 24-hour availability of nursing care. Inpatient care may be appropriate if the patient requires treatment by multiple other rehabilitation professionals (e.g, physical therapists, occupational therapists, speech language pathologists, and psychologists).
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Summary Guideline Management of Stroke Rehabilitation
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Annotation N. Educate Patient/Family; Reach Shared Decision Regarding Rehabilitation Program; Determine and Document Treatment Plan
7.3 Treatment Plan
RECOMMENDATIONS
1. Patients and/or their family members should be educated in order to make informed decisions and become good advocates.
2. The patient/family member’s learning style must be assessed (through questioning or observation) and supplemental materials (including handouts) must be available when appropriate.
3. The following list includes topics that (at a minimum) must be addressed during a patient’s rehabilitation program:
a. Etiology of stroke
b. Patient’s diagnosis and any complications/co-morbidities
c. Prognosis
d. What to expect during recovery and rehabilitation
e. Secondary prevention
f. Discharge plan
g. Follow-up care including medications.
4. The clinical team and family/caregiver should reach a shared decision regarding the rehabilitation program.
5. The rehabilitation program should be guided by specific goals developed in consensus with the patient, family, and rehabilitation team.
6. Document the detailed treatment plan in the patient's record to provide integrated rehabilitation care.
7. The patient's family/caregiver should participate in the rehabilitation sessions, and should be trained to assist patient with functional activities, when needed.
8. As patients progress, additional important educational topics include subjects such as the resumption of driving, sexual activity, adjustment and adaptation to disability, patient rights/responsibilities, and support group information.
The treatment plan should include documentation of the following:
• Patient’s strengths, impairments, and current level of functioning
• Psychosocial resources and needs, including caregiver capacity and availability.
• Goals:
personal goals (e.g., I want to play baseball with my grandson.)
functional goals (e.g., ADL, IADL, mobility)
short term and long term goals
• Strategies for achieving these goals, including :
resources and disciplines required
estimations of time for goal achievement
educational needs for patient/family
• Plans and timeline for re-evaluation
Version 2.0 VA/DoD Clinical Practice Guideline for the
Summary Guideline Management of Stroke Rehabilitation
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Annotation O. Initiate/Continue Rehabilitation Programs and Interventions
7.4 Treatment Interventions
RECOMMENDATIONS
1. Initiate/continue rehabilitation program and interventions indicated by patient status, impairment, function, activity level and participation.
See Section 9: Rehabilitation Interventions
a. Dysphagia
Impairments
b. Muscle Tone
c. Emotional, Behavioral
d. Cognitive
e. Communication
f. Motor
g. Sensory
a. ADL/IADL
Activity
b. Mobility
c. Sexuality
d. Fitness Endurance
a. Psychosocial needs/resources
Support System
b. Family/Community Support
c. Caregiver
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Summary Guideline Management of Stroke Rehabilitation
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Annotation P. Reassess Progress, Future Needs and Risks. Refer/Consult Rehabilitation Team
7.5 Assessment of Progress and Adherence
RECOMMENDATIONS
1. Patients should be re-evaluated intermittently during their rehabilitation progress. Particular attention should be paid to interval change and progress towards stated goals.
2. Patients who show a decline in functional status may no longer be candidates for rehabilitation interventions. Considerations about the etiology of the decline and its prognosis can help guide decisions about when/if further rehabilitation evaluation should occur.
3. Psychosocial status and community integration needs should be re-assessed, particularly for patients who have experienced a functional decline or reached a plateau.
Annotation Q. Is Patient Ready for Community Living?
7.6 Transfer to Community Living
RECOMMENDATIONS
1. Recommend that all patients planning to return to independent community living should be assessed for mobility, ADL, and IADL prior to discharge (including a community skills evaluation and home assessment).
2. Recommend that the patient, family, and caregivers are fully informed about, prepared for, and involved in all aspects of healthcare and safety needs. [I]
3. Recommend that case management be put in place for complex patient and family situations. [I]
4. Recommend that acute care hospitals and rehabilitation facilities maintain up-to-date inventories of community resources, provide this information to stroke patients and their families and caregivers, and offer assistance in obtaining needed services. Patients should be given information about, and offered contact with, appropriate local statutory and voluntary agencies. [I]
7.7 Function/Social Support
RECOMMENDATIONS
1. Patients and family caregivers should have their individual psychosocial and support needs reviewed on a regular basis post-discharge.
2. Referrals to family counseling should be offered. Counseling should focus on psychosocial and emotional issues and role adjustment.
3. Caregivers should be screened for high levels of burden and counseled in problem solving and adaptation skills as needed.
4. Caregiv