Assessment for Rehabilitation: Pathway and Decision-Making Tool

Australian Stroke Coalition

Assessment for Rehabilitation: Pathway and Decision-Making ToolSusan Hillier on behalf of the ASC Rehabilitation Working Group and SA Stroke Network


Learning objectives

This presentation will enable you to:– Recognise the importance of standardised

rehabilitation assessment for people with stroke

– Introduce the recommended rehabilitation pathway after stroke

– Explain who should receive rehabilitation and the four exceptions


Learning objectives (cont)

– Explain how to use the Rehab Assessment and Decision-Making Tool

– Determine the appropriate rehabilitation setting using the Rehab Assessment and Decision-Making Tool

– Determine the degree and nature of rehabilitation (domains) using the Rehab Assessment and Decision-Making Tool


Background• Currently only 41% of people with stroke are

assessed for rehabilitation (NSF 2011)• Processes for Ax are highly variable and

inconsistent between individual assessors (Kennedy, in press)

• Ax is often based on non-clinical factors (Hakkennes 2011) or based on clinical factors that do not have a relationship with rehabilitation outcomes


Background (cont)

• Ax is often not based on a person’s capacity to improve (Ilet 2010)

• Assessment processes are poorly documented

• All leading to the potential for ad hoc and potentially unfair decision making


Assessment for Rehabilitation: Pathway and Decision-Making Tool

Australian Stroke CoalitionAims • All stroke survivors in Australia should be

assessed for rehabilitation• This assessment should be:

– Accountable, timely and transparent– Fair and consistent– Based on needs, not service availability, in the

first instance– Include person, multidisciplinary team, family– Based on best available evidence


Who should receive rehabilitation?• Stroke survivors may be rejected or never

considered for rehabilitation due to:– Age– Rehab services not able to cater for severity

or co-morbidities– Lived alone prior to stroke– Potential for long stay– Poor relationships between service providers– Deemed ‘not likely to benefit’


Who should receive rehabilitation?

HOWEVER• A systematic literature search failed to identify

any clear indicators (clinical or otherwise) that could be used to determine ineligibility or unlikely to benefit from Rehab.

• It is therefore recommended that ALL STROKE SURVIVORS RECEIVE REHAB unless they meet one of the four exceptions.:


Exceptions to rehabilitation

1. Return to pre-morbid function: Stroke survivor has made a full recovery in all aspects including physical, emotional, psychological and cognitive.

2. Palliation: Death is imminent; refer to the palliative care team.


Exceptions to rehab (cont.)3. Coma and/or unresponsive, not simply drowsy: Determined by criteria for minimally responsive, i.e. responds to stimuli meaningfully as able.

4. Declined rehabilitation: Stroke survivor does not wish to participate in rehabilitation.

• If a stroke survivor meets any of these exceptions, regular monitoring is required to evaluate whether the exception is ongoing


Pathway (cont)Flags include:• Premorbid conditions +/-

↓premorbid function• Severe cognitive

impairment• High level medical/surgical

acuity• Non-compliance, apathy• ↓social support/

accommodation options• Double incontinence

• Somatoform disorders• Co-morbidities (particularly

those associated with ageing)


When, where and who uses the Rehab Decision-Making Tool

• Evidence suggests that rehabilitation should begin as early as possible (Bernhardt 2008) so assessment for rehabilitation should also be early.

• Pilot testing suggests commencing the process 48 hours after admission to help guide patient management.

• The Decision-Making Tool should be used in stroke units, but it can be used in other settings


When, where and who uses the Rehab Decision-Making Tool

• MDT members complete the sections relevant to their practice and/or

• The tool can be completed at a meeting with the MDT and the family or at ward rounds, formal or informal review meetings or within other local processes

• With familiarity takes about 10 minutes• Can be updated as required during the hospital

stay


Environment and participation documentation• In order to provide a more complete picture of

the stroke survivor and their rehabilitation needs there are two further tables (consistent with the WHO ICF model):

• Participation – this documents previous roles and need for rehabilitation

• Environment – documenting pre-stroke environment and flagging need for intervention if barriers identified


Example of participation section

Participation (consistent with ICF Framework) Roles/s pre-stroke

Need for rehabilitation/intervention?Y/N and if yes, plan?

Domestic Helped with cooking/cleaningServiced cars and did majority of gardening

Y – incorporate raised bed gardening tasks in rehab

Vocational Accountant Y – incorporate book-keeping tasks in SP sessions

Recreational Classic car club member Y – attend meetings, friends rostered to assist with transport and access

Social Local pub for Friday drinks N – able to resume attendance (light beer)


Example of environment section

Environment Pre-stroke (note barriers and facilitators)Need for intervention?Y/N and if yes, plan?

Home Two storey house, bedroom upstairs, downstairs shower and toilet with guest bedroom accessible/Wide home for 6/12 LSL; family available on roster for respiteOne stair to backdoor, front door no steps. Shed accessible.

Y – needs rail in downstairs toilet and bathroom; pole for bed; ramp + rail for backdoor.

Extended Car club rooms two steps; car park 5m from room.Local pub – accessibleAccountancy firm - accessible

N – but monitor and instigate plan as necessary


Summary1. Pathway - Consider exceptions to

rehabilitation. If they do not apply proceed with decision making tool

2. Decision making tool:– Domains – level of in/dependence plus– Need for rehabilitation and level– Where– Participation and environmental

considerations


Implementation

We recommend a clear implementation process:1. Raise awareness of pathway and tool

generally in your institution2. (Conduct audit of current practice)3. Hold formal education session/s to become

familiar with details and processes4. Discuss implementation as a team

- Facilitators such as site champion- Barriers such as misunderstandings,

time, resistance to documentation


Additional slides: 1. Working group members – ASC and SA Stroke Network2. Methods for initial project3. Pilot results4. Modifications


ASC Rehabilitation working group:Overall mission: People with stroke should receive the right rehabilitation, at the right time, in the right place………..

• Dr Geoff Boddice• Dr Greg Bowring• Ms Cindy Dilworth• Dr David Dunbabin• Dr Steven Faux• Dr Howard Flavell• Ms Megan Garnett• Dr Erin Godecke• Dr Kong Goh• Dr Andrew Granger

• Dr Susan Hillier (chair)• Dr Genevieve Kennedy• Ms Sandra Lever• Dr Natasha Lannin• Mr Bill McNamara• Ms Jill McNamara• Ms Juvy McPhee• Mr Chris Price• Ms Frances Simmonds• Ms Leah Wright


SA Network Rehabilitation working group:Susan Hillier (Chair), Jodie Aberle, Peter Anastassiadis, Kelli Baker, Elizabeth Barnard, Matt Barrett, Gillian Bartley, Peter Bastian, Maryann Blumbergs, Maree Braithwaite, Jordie Caulfield, Amanda Clayton, Denise Collopy, Maria Crotty, Michelle Curtis, Robyn Dangerfield, Grant Edwards, John Forward, Caroline Fryer, Kendall Goldsmith, Carole Hampton, Peter Hallett, Robyn Handreck, Tony Hewitt, Patricia Holtze, Theresa Hudson, Venugopal Kochiyil, Catherine Lieu, Shelley Lush, Elizabeth Lynch, Annette McGrath, Antonia McGrath, James McLoughlin, Jo Murray, Lee O’Brien, Debra Ormerod, Elizabeth Sloggett, Sally Sobels, Yvonne Tiller, Roly Vinci, Anne Walter, Lauri Wild, Brad Williams, Cathy Young.

Australian Stroke CoalitionAim: to devise a process for assessing people for stroke rehabilitation, that is clear, consistent and based on need in the first instance.

Method: National survey of current

practice

Expert working groups

Systematic search

of the literature** Funding from

Bayer Australia

52 sites

40 great minds

104 articles


Piloting – in sites in most states (n=6)

Positives:• ensured clear and accountable decision-making, • focused on the person with stroke and their

family (not services)• Increased involvement of all stroke team

members• More wholistic as based on the ICF-WHO

framework.


Piloting – in sites in most states (n=6)

Negatives:• Already do it• Haven’t got time• No outcome measures• Unrealistic because some people

don’t improve with rehabilitation


Changes and additions

• Wording • Recommend commences in first 48 hrs –

at minimum within first week• Done at team meetings with family if at all

possible and updated similarly• Can be championed by one person but

needs whole team input• Use as handover between services


Changes and additions

• Initially time consuming but with practice can be 10 mins

• Format that can be adapted to suit local record keeping

• Maintain integrity of intention• Useful for stroke survivor/family ? as held record• Stress this is survivor-centred and services may

not exist to match identified need (YET)


For further information about the Rehabilitation Assessment and Decision-making tool please contact either:

Susan Hillier – [email protected]

Leah Wright – [email protected]

mailto:[email protected]

mailto:[email protected]

Assessment for Rehabilitation: Pathway and Decision-Making Tool

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