Assessment of Stroke Rehabilitation in Nebraska Hospitals

1. Assessment of Stroke Rehabilitation in Nebraska Hospitals Feb 23, 2011 Katherine J. Jones, PT, PhD Teresa Cochran, PT, DPT, GCS, MA Lou Jensen, OTD, OT/L Tammy Roehrs, PT, MA, NCS Kathleen Volkman, PT, MS, NCS Amy Goldman PT, DPT Supported by the Nebraska Department of Health and Human Services, Cardiovascular Health Program PHOTO GOES HERE (Need higher resolution

2. Funding & Acknowledgements • Supported by the Nebraska Department of Health and Human Service, Cardiovascular Health Program • Robin High, MA for assistance with statistical analysis • Anne Skinner, RHIA for database construction • Andrea Bowen, BA for data entry and table formatting • Clinicians across the state who assisted in instrument construction

3. Objectives • Explain a framework to assess health care quality • Describe the structure and process of stroke rehabilitation in Nebraska hospitals • Identify two factors that predict variability in the prevalence of evidence-based structures & processes • Discuss options to improve access to evidence-based stroke rehabilitation for survivors of stroke in Nebraska

4. Purpose of the Study • Assess the structure and process of acute stroke rehabilitation in a representative sample of Nebraska hospitals • Determine the extent to which reported structures and processes are consistent with current evidence relative to stroke rehabilitation • Develop an action plan to increase the prevalence of evidence-based structures and processes for acute stroke rehabilitation in Nebraska hospitals

5. What is Quality? • “The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”* • “The greatest good that is possible to achieve in any given situation.” – Donabedian, 1980 • Avoid “underuse, overuse, misuse…” – National Roundtable on Healthcare Quality, 1998 *Institute of Medicine (IOM). (2001). Crossingthe quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.

6. Donabedian’s Framework to Assess Quality • Quality is inferred by measuring elements of care • Structure–conditions under which care is provided (human resources, equipment, environment) • Process–what was done (diagnosis, treatment, rehabilitation, prevention, patient education) • Outcome–changes in individuals and populations that are due to health care Structure Process Outcomes Donabedian, A. (1980). The definition of quality and approaches to its assessment. Ann Arbor, Michigan: Health Administration Press.

7. Advantage “Ultimate validator” of quality Limitations Determined by multiple factors Time to develop (survival) Difficult to measure (role resumption, attitudes) Knowledge of relationship between process and outcomes ? Ability to reveal processes responsible for outcomes? Assessing Outcomes to Infer Quality Donabedian, A. (1980). The definition of quality and approaches to its assessment. Ann Arbor, Michigan: Health Administration Press.

8. Advantages Equivalent to system design, capacity for work Major determinant of average quality of care Readily observable, easily documented, stable Limitation Variations must be large to validly judge quality Assessing Structure to Infer Quality Donabedian, A. (1980). The definition of quality and approaches to its assessment. Ann Arbor, Michigan: Health Administration Press.

9. Advantages Most closely related to outcomes Small variations in process can be related to variations in outcomes Limitations Must establish causal relationship between process and outcomes Understand role of medical beliefs, traditions Understand complexity of process inputs Assessing Process to Infer Quality Donabedian, A. (1980). The definition of quality and approaches to its assessment. Ann Arbor, Michigan: Health Administration Press.

10. Patient Clinical Risk Factors • Baseline cognitive and functional status before disease or injury • 2. Clinical status (severity) Treatment Characteristics Structure of Care Process of Care • Outcomes of Care • Patient • a. Disease specific – lab values, X-ray • b. Holistic – quality of life, ADLs • 2. Provider – infection rate • 3. Organization – Length of Stay, Ambulatory Care Sensitive adms. • 4. Payer – Cost • Patient Demographic & • Psychosocial Risk Factors • Age 6. Occupation • 2. Gender 7. Education • 3. Race 8. Depression • 4. Marital status 9. Residence • 5. Social Support Kane RL. Understanding Health Care Outcomes Research. Gaithersburg, MD: Aspen Publishers;1997.

11. Stroke Rehabilitation Rationale Stroke rehabilitation is the holistic, comprehensive approach to addressing the physical, psychological, social, educational, and vocational needs of individuals with stroke.1 The structure and process of stroke rehabilitation determine its outcomes. Access to coordinated systems of stroke care may be limited in rural areas.2 • Keith RA. The comprehensive treatment team in rehabilitation. Arch Phys Med Rehabil. 1991;72:269-274. • Schwamm LH, Pancioli A, Acker JE,3rd, et al. Recommendations for the establishment of stroke systems of care: Recommendations from the American Stroke Association's task force on the development of stroke systems. Stroke. 2005;36:690-703.

12. Stroke Rehabilitation Rationale • Interprofessional team = Foundation of structure • Standardized assessments = Key element of process • Document baseline, progress, outcomes • Identify pt’s at risk • Determine need for addl therapies • Facilitate team communication, planning

13. Consistent with IOM Competencies Institute of Medicine. Health Professions Education: Bridge to Quality. Washington, DC: The National Academies Press; 2003; p. 46.

14. Stroke Rehabilitation Rationale • Barriers to use of Standardized assessments • Time • Lack of peer support • Lack of information systems • Lack of library of assessments • Difficulty interpreting • Perception that they are more relevant to research than clinical care

15. Limited Access in Rural?

16. Short Length of Stay in IRFs • 16.5 day…avg IRF LOS • 58% discharged to home • 20% discharged to SNF • Rural stroke survivors likely access post-IRF outpatient, home-health, or skilled nursing care from a CAH

17. Methods • Instrument validated by expert panel • Design: cross-sectional mail survey Jan–Mar 2010 • Stratified random sample of 53/84 Nebraska hospitals that provide acute stroke rehabilitation • Verified target recipient: person most knowledgeable about stroke rehabilitation in each facility • 36/53 hospitals returned survey (68% response rate) • Analysis • PROC SURVEYMEANS to estimate statewide means, • Fisher’s Exact Test, ANOVA, and logistic regression to examine associations between hospital size and team structure with practices consistent with current evidence for stroke rehabilitation

19. Methods: Sample Weighting

20. Results • Structure of stroke rehabilitation care • Professionals • Team structure • Access to specialized services • Use of standardized assessments • Team Processes • Purpose of standardized assessments • Barriers to standardize assessments • Quality improvement

23. Team Structure of Stroke Rehabilitation Care in Nebraska Hospitals

24. Use of Standardized Assessments and Access to Specialized Services in Stroke Rehabilitation by Hospital Size

25. *p<0.05)

26. *p<0.05)

27. Stroke Rehabilitation Quality Improvement by Team Structure and Hospital Size *p<.05 No team vs. team † p<.05 47 – 689 Beds vs CAH

28. Strengths and Limitations • Strengths • Expert panel ensured face validity of instrument • Stratified random sample enabled statewide est. • Adequate response rate (68%) • Limitations • Assessed structure and process by self report • Did not assess outcomes • Small sample size limits power

29. Summary • Stroke survivors receiving rehabilitation in CAH setting • Limited access to interprofessional team care • Limited access to specialized services • Less likely to receive standardized assessments • Stroke rehabilitation care in CAHs • Less likely to collect outcome data or engage in QI • Barriers to use of standardized assessments do not vary by hospital size • Hospitals with formal teams use assessments to guide care • 60% of hospitals interested in collaboration to improve use of standardized assessments, access to services

30. Conclusion Due to short lengths of stay in IRFs, the structure and process of stroke rehabilitation must be consistent with the IOM competencies across the continuum of settings. Future research needed: • Is team structure a determinant of post-IRF stroke rehabilitation outcomes? • What are the specialized service needs of rural stroke survivors and their caregivers? • How can technology facilitate use of stroke rehabilitation standardized assessments?