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Australian Stroke Coalition
Assessment for Rehabilitation:
Pathway and Decision-Making Tool
Susan Hillier on behalf of the ASC Rehabilitation Working Group and SA Stroke Network
Australian Stroke Coalition
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
Australian Stroke Coalition
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
Australian Stroke Coalition
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
Australian Stroke Coalition
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
Australian Stroke Coalition
Assessment for Rehabilitation:
Pathway and Decision-Making Tool
Australian Stroke Coalition
Aims • 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
Australian Stroke Coalition
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’
Australian Stroke Coalition
Who should receive rehabilitation?
Australian Stroke Coalition
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.
Australian Stroke Coalition
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
Australian Stroke Coalition
Pathway (cont)
Australian Stroke Coalition
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
Australian Stroke Coalition
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
Australian Stroke Coalition
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
Australian Stroke Coalition
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)
Australian Stroke Coalition
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
Australian Stroke Coalition
Summary
1. 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
Australian Stroke Coalition
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
Australian Stroke Coalition
Additional slides: 1.Working group members – ASC and SA Stroke Network2.Methods for initial project3.Pilot results4.Modifications
Australian Stroke Coalition
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
Australian Stroke Coalition
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 Coalition
Aim: to devise a process for assessing people for stroke rehabilitation, that is clear, consistent and based on need in the first instance.
Method:
* Funding from Bayer Australia
52 sites
40 great minds
104 articles
Australian Stroke Coalition
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.
Australian Stroke Coalition
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
Australian Stroke Coalition
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
Australian Stroke Coalition
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)
Australian Stroke Coalition
For further information about the Rehabilitation Assessment and Decision-making tool please contact either:
Susan Hillier – [email protected]
or
Leah Wright – [email protected]