AN INTERPROFESSIONAL APPROACH TO PATIENT CARE

Numerous studies have indicated that the most successful model for reintegration into the community for stroke patients is one that incorporates a multidisciplinary/interprofessional team approach (Stroke Unit Trialists’ Collaboration, 2013). The review concluded that patients who received care from an organized stroke unit team had a higher likelihood of surviving the stroke, regaining their prestroke independence, and returning home than those who did not receive care from a team approach. Beginning on day 1 of admission, the role of the interprofessional team is to evaluate the stroke patient’s functional status and determine the best fit for postacute rehabilitation treatment (Clarke, 2013). Key members of the team include physicians such as neurologists; internist, physiatrist, along with any other consulting physicians; advanced practice nurses (APNs) (nurse practitioners [NPs], clinical nurse specialists [CNSs]) and physician assistants (PAs); nurse case manager; social worker; therapists (occupational, physical, and speech therapy); bedside nurses; pharmacist; and other ancillary disciplines represented on the interprofessional stroke team. Each team member must assess the patient and identify both strengths and barriers in the patient’s current condition and communicate the findings to the other team members. Ongoing communication regarding the patient’s status is most effectively coordinated through the use of team meetings, daily rounds, or chart documentation (electronic medical record [EMR] or paper chart).

Team Member Roles

Each member of the interprofessional team has both individual and collaborative roles within the team to contribute to the timely and efficient transition of the patient along the postacute care continuum. The following briefly describes these roles.

Physician. The physician’s role in evaluating the appropriate postacute care plan is to determine what poststroke conditions will impact the patient’s ability to safely return to the community. It is necessary to identify what cognitive and behavioral deficits the patient has because these deficits will impact on decisions regarding selection of rehabilitation treatments that will be most appropriate for the patient.

NPs, CNSs, and PAs. The role of the NP, CNS, and PA is to provide ongoing comprehensive care and coordination for the patient while in the acute setting and ensure that physicians and other team members are kept abreast of the patient’s status. Additionally, they provide detailed assessments of the patient’s strengths and barriers to successful reintegration to the community. In many acute care settings, it is the NPs, CNSs, or PAs who provide stroke education to patients and families.

Pharmacist. The pharmacist plays an important role on the team. Many stroke patients are already on medications prior to admission or will require medication management going forward. Patients may be prescribed a variety of medications including anticoagulation therapy, cholesterol-lowering medication, blood pressure medications, anticonvulsants, and diabetes management medications. Pharmacists may also participate in patient/family caregiver education on dosing instructions, side effects, and drug interactions of the medications the patient will be taking. Particular attention to discussions regarding medication compliance is important component of patient education and critical to avoidance of secondary stroke.

Nurse case manager. The role of the nurse case manager is to evaluate the appropriate options available to the patient based on insurance/resources in order to move the patient to the next appropriate level of care. There are a number of options available including a skilled nursing facility (SNF), acute rehabilitation facility (ARF), long-term acute care hospital (LTAC), or home with appropriate durable medical equipment and ongoing outpatient therapy. Appropriateness or best fit of any of these facilities will be determined by the team. The nurse case manager has to consider cost-effectiveness for the hospital while also considering the family’s wishes and the best interest of the patient, keeping safety in mind at all times. The nurse case manager must work closely with the patient’s insurance company to determine what benefits are covered.

Social worker. The role of the social worker, often in conjunction with the nurse case manager, is to explore the psychosocial impact of the illness on the patient and family and determine what resources, both financial and emotional, will be necessary for the patient to successfully transition back into the community. The social worker has three primary responsibilities: to assess the patient for psychosocial factors that could impact discharge plans, to help connect families with relevant community resources, and to provide emotional support and guidance to patients and their families.

Therapists. Occupational therapists, physical therapists, and speech therapists play a key role in the discharge planning process by communicating the patient’s capabilities and deficits to the discharge planner and physician. These skilled therapists will also play an important role in the posthospitalization care process. They are able to assess the progress made in functional recovery from the rehabilitation activities completed during the acute care hospitalization. The goal of rehabilitation is to improve function so that the stroke survivor can become as independent as possible. This must be accomplished in a way that preserves dignity and motivates the survivor to relearn basic skills and activities of daily living that the stroke may have taken away. The individual therapists can determine what functional goals have been achieved and what will need to be addressed at the next level of care so that these needs are addressed in the plan of care at discharge.

Occupational therapist: The occupational therapists’ role in the discharge process is to assess the patient’s ability to perform activities of daily living, such as feeding, bathing, dressing, and toileting. They also perform assessments for wheelchairs and other adaptive devices to improve the patient’s functional status when leaving the hospital.

Physical therapist: Physical therapists perform assessments of the patient’s gait, balance, mobility, and sensory deficits. Based on their assessment of the patient, they design individualized programs aimed at regaining control over motor functions.

Speech therapist: Speech therapists evaluate the patient for language deficits and identify methods to communicate using alternative means of communication. They also help patients improve their ability to swallow, and they work with patients to develop problem-solving and social skills needed to cope with the aftereffects of a stroke (National Institute of Neurological Disorders and Stroke [NINDS], 2014). See Chapter 10 for further details on rehabilitation and transitions.

Bedside nurses: The bedside nurses’ role is extremely important. They develop an understanding of the person’s medical condition while in the hospital and see the family and caregiver interactions. The nurses’ regular observations of the patient’s conditions provide valuable information to medical staff in determining how well the patient will function when returning to the community. Nurses work closely with the patient and family/caregivers to provide education and training regarding the risk factors for secondary stroke and recognition of stroke signs and symptoms.

Postacute Rehabilitation Options

There are a variety of postacute models of care that may be appropriate for the discharging stroke patient. Determining which level of care that will best meet the needs of an individual patient begins very quickly upon admission to the hospital. The case manager will most often contact the patient’s insurance company immediately to determine the specific benefits to which of the patient is entitled. This is important to do early because often the insurance company case manager will need to assess the patient independently to approve benefits. It is also necessary to have the insurance company involved early because the approval process for the next level of care can be time-consuming. It is the responsibility of the case manager to ensure the timely discharge of the patient to next level. The case manager will also coordinate all of the assessments from the interprofessional team to make a recommendation on behalf of the team to the insurance company for their approval.

The determination of the level of care postacute is made based on a number of criteria, most of which are based on the team’s recommendation along with guidelines set out by the Centers for Medicare and Medicaid Services (CMS). Depending on the extent of rehabilitation services still required to best meet the needs of the patient, the following options may be available:

●    LTACs

●    ARFs

●    SNFs

●    Home with support from home health services

●    Home with outpatient therapy

●    Palliative care or hospice care

In some cases, the patient may eventually require care offered in a long-term care facility. Unfortunately, in most cases, the cost of long-term care is not covered by insurance and is considered to be self-pay or self-funded. At the other end of the spectrum, many patients experience no lingering effects from the stroke and are able to return home with no postacute rehabilitation needs. They are advised to follow up with their primary care provider, which should include secondary prevention of stroke through the identification and management of stroke risk factors.

The highest level of care available after discharge from the acute care hospital is a long-term acute care hospital known as an LTAC. This level of care is appropriate for those patients who no longer require an acute care setting but whose functional status has not improved enough to move to a lower level of care. Most often, patients are discharged to an LTAC when they require more complex medical care than is provided in an SNF but less care than is needed in an acute care setting. The patient’s need for nursing and rehabilitative services are complex enough that only an inpatient LTAC setting can meet the requirements, and the expected length of stay is greater than 25 days (for shorter stays, consider SNP or an inpatient rehabilitation facility). Many LTAC-appropriate patients have primary medical or respiratory problems that are complex, requiring daily intervention by a physician, NP, or PA with intensive treatment.

The next level of care available to the stroke patient is the SNF. In this setting, the patient is required by Medicare (and in turn, private insurers) to be able to participate in a minimum of 3 hours of skilled therapy (occupational therapy [OT]/physical therapy [PT]/speech therapy [ST]) per day. Individuals in SNFs also still require nursing care and limited physician care. This level of care is ideal for patients who are not yet capable of managing the endurance required for the inpatient rehabilitation hospital setting. Fewer hours of therapy are offered at SNFs compared to inpatient rehabilitation units. SNFs are an excellent choice for patients who have endurance issues. The average length of stay for a stroke patient in an SNF is 7.15 days (American Health Care Association, 2011). Medicare patients must have spent three overnights (72 hours) in an acute care hospital in order to meet criteria for SNF benefit. Medicare part A (hospitalization) benefits provide a total of 100 days of skilled nursing. The breakdown of out-of-pockets costs to the patient is as follows (Medicare, 2014):

For those patients with private insurance, benefits vary significantly by policy.

Another level of care that is commonly used for stroke patients is ARFs, either in a freestanding rehabilitation facility or within the acute hospital setting. Studies have shown that providing rehabilitation services in an ARF improves the quality of life and functional status of stroke patients significantly.

Patients typically stay in the facility for 2 to 3 weeks and participate in a coordinated, comprehensive, intensive program of rehabilitation. These programs involve at least 3 hours of active therapy daily, 5 or 6 days a week. Inpatient facilities offer a comprehensive range of medical services, including full-time physician supervision and access to a full range of therapists specializing in poststroke rehabilitation (NINDS, 2014). The average length of stay for stroke patients in a rehabilitation facility is typically 28 days and is considered a covered benefit under Medicare part A (hospitalization) along with acute hospital coverage. Again, private insurance coverage varies by policy and often covers a much more limited number of days than Medicare.

For those patients who are able to return home, whether directly from the acute care setting or from an SNF, rehabilitation hospital, or LTAC, the use of home health services is an additional source of ongoing rehabilitation. Home health service is a covered benefit under Medicare which requires that the patient be homebound and unable to leave the home to obtain outpatient therapy. Additionally, the patient must have at least one skilled need consisting of nursing care, OT, PT, or ST

In some cases, it is possible for the patient and family to also receive the services of a home health aide to provide a few hours a week of care for the patient or respite for the caregiver. The aide typically assists the patient with bathing and grooming activities. A social worker is also available as needed to provide supportive counseling for the patient and caregivers as well as provide resources in the community such as support groups.

Home health services are a covered benefit under Medicare and typically involve three visits per week by the individual therapist or nurse as needed. Those patients with private insurance may carry a home health benefit although, due to lower reimbursement rates by insurers, it is more difficult to find providers who will accept private insurance patients. In these cases, it is often helpful to contact the insurance company directly for assistance. If the patient has been assigned a case manager with the insurance company, this is the best place to start.

For those patients with minimal skilled therapy needs and the ability to travel for services, outpatient therapy is an excellent option. Outpatient therapy services (OT/PT/ST) are often provided through the larger rehabilitation hospitals but are also available at many locations within a community, making it more accessible for the patient and his or her caregivers. It is often part of a continuum of therapy services that began while in the acute care setting. Patients typically attend therapy sessions 2 to 3 days a week (Mosunmola, Adler, & Barrett, 2014). Depending on individual needs, the patient may require OT/PT or ST, often all three. Many stroke survivors use outpatient therapy services for many years following a stroke. As plateaus are reached, the patient is often discharged to “take a break.” The patient can always be reevaluated by his or her physiatrist to assess to determine whether the patient is appropriate to restart therapy in the future.

Services are provided through Medicare under part B (medical), which covers 80% of costs. It is recommended that the patient obtain Medicare gap coverage, which typically covers the 20% not covered by Medicare. There are “caps” imposed on outpatient therapy. For 2014, the cap is $1,920 for PT and speech-language pathology (SLP) services combined and $1,920 for OT services (Medicare, 2014). With appropriate documentation from the various therapists, it is possible to exceed the caps up to $3,700 for PT and ST combined and $3,700 for OT. Private insurers most often provide outpatient therapy as a covered benefit, although each policy varies as to the number or visits provided.

Palliative care or hospice services are another option for the stroke patient. This is reserved for those patients who have suffered the most severe stroke and are not expected to survive longer than 6 months. Patients who have suffered a massive stroke may qualify for hospice care either during the acute phase of the stroke or as a chronic condition many years after the stroke. Criteria for admission onto hospice care (Group Health Cooperative, 2014) include the following:

●    Comatose patients with any four of the following on day 3 of a stroke have 97% mortality by 2 months:

●    Abnormal brainstem response

●    Absent verbal response

●    No response to pain

●    Serum creatinine of more than 1.5 mg/dL

●    Age 70 years or older

●    Dysphagia severe enough to prevent them from receiving food or fluids

●    Karnofsky score of poor performance status 40% or less

●    Poor nutritional status

Hospice is a 100% Medicare-covered benefit and provides a comprehensive network of services intended to provide comfort care and support for the patient and the family. In addition to the medical services provided by the hospice nurse, the patient and family also receive supportive services from chaplains and social workers and 1 year of bereavement services following the death of the patient. Hospice benefits are covered at 100% by Medicare and most private insurers. See Chapter 9 for further discussion of palliative care.

  PREPARING FOR DISCHARGE

Preparing both the patient and the caregivers for discharge should begin immediately upon admission to the hospital. There are many factors to consider when preparing the patient for discharge to the next level of care (Duncan et al., 2005). In the early stages, it may not be possible to identify which level of care will be appropriate at the time of discharge; however, there are a number of steps that can be implemented early in the acute hospitalization.

One of the first steps in preparing the family for discharge is to conduct a formal psychosocial assessment, typically completed by the social worker. The assessment should address both the patient as well as the family/caregivers and include areas such as history of prestroke functioning (e.g., demographics, past medical and social history, emotional functioning, mental health history, education and employment history, veteran status, and legal aspects including any advance directives, powers of attorney, support systems, and coping mechanisms).

Additional elements of a comprehensive psychosocial assessment will include a thorough exploration of the relationships within the family system and what spiritual and cultural preferences are important to the patient and family that may impact successful transition to the community. An understanding of the family’s resource needs is crucial to identify early in the process. Financial considerations have a huge impact on the patient’s eligibility for various types of postacute rehabilitation services. If the patient is going home, it is critical to determine if the home is safe and accessible for someone who is disabled. This assessment can be provided through the services of a home health agency. With a physician referral, the home health nurse can conduct an in-home assessment and provide feedback and recommendations to the family/caregivers on how to equip the home to the meet the needs of individual patient. Examples of ways to make the home safe are moving area rugs out of the way to avoid risk for falls, installation of ramps to get in and out of the home using a wheelchair, and grabbing bars near toilets and showers.

Most importantly, the assessment needs to identify what the patient/family/caregiver perceptions are of the condition, treatment plan, and prognosis and what the hopes and expectations are for ongoing care of the patient (Duncan et al., 2005). The importance of family involvement in the care and planning cannot be emphasized enough. Patients with high levels of family support have been shown to increase the likelihood of return to home after hospital admission and a decreased chance of unscheduled readmission (Tsouna-Hadjis, Vemmos, Zakopoulus, & Stamatelopoulos, 2000).

Family/caregiver education includes programs that promote lifestyle changes and identify barriers to implementing these changes along with providing strategies to overcome the obstacles. In addition, education addresses the needs of the patient regarding his or her specific condition and care, treatment, and prevention. Caregivers are also provided with information regarding services that are available in the community including support group information, respite care, and social service support (The Joint Commission, 2013).

It is imperative that the interprofessional team document within the patient’s medical record to reflect the patient and family/caregiver education. Formal documentation of all interventions, education, and training that are provided to the patient and family/caregivers must be completed, including an assessment of the family’s level of understanding of the information that was provided.

The case manager will evaluate the financial resources and insurance benefits that will be available to the patient. In addition, if the patient is discharging directly home, the case manager will determine what, if any, durable medical equipment will be necessary such as a hospital bed, walker, wheelchair, and speech aides. To identify what PT and OT equipment will be necessary, collaboration with the physiatrist and OT/PT/ST team is important.

Family training and assessing the patient and the family caregiver’s readiness to provide caregiving for the patient, once discharged from the acute setting, should begin as early as possible after the patient’s admission. This task is often challenging because the family is typically in shock and overwhelmed by the circumstances and uncertainty surrounding the event and unable to process the extent of the ongoing challenges that the family will face. Caregivers may still be dealing with the unexpected challenge of balancing family and work commitments with visitations at the hospital. There may be young children at home who require care. For older stroke patients and their families, the spouse may have serious health problems and thus be unable to participate in the ongoing care needs of his or her disabled spouse. In this case, additional family support is crucial to getting the patient on the road to rehabilitation.

As part of the initial assessment, gathering an understanding of who will be involved in the ongoing care of the patient and ensuring they are included in all training activities and family meetings will assist in facilitating a successful discharge to the next level of care. It is important that family/caregivers are included in all decision making and treatment planning for the patient. In addition, it is essential to determine who the family decision maker is and if there is a different family member who may act as the spokesperson because they may not always be the same person. In cases where the patient is unable to make his or her own decisions, the team should determine whether the patient has completed a power of attorney document and who is legally designated to make decisions on behalf of the patient.

All staff should monitor for signs of stress in the family caregivers especially as it relates to the patient’s residual impairments such as speech and physical limitations, cognitive loss, personality changes, and incontinence issues (Duncan et al., 2005). Caregivers are often heard to say “There is no way I will be able to manage the needs of my loved one at home. He or she needs to stay here at the hospital until he or she gets back to normal.” Of course, this is not realistic, and it is the responsibility of the care team to ensure that the family/caregivers are given the emotional support and resources to build confidence so that they will indeed be able to care for the patient upon discharge to next level of care.

Special attention must be paid to the “walking wounded,” those patients who are physically well enough to return home but may be suffering from significant cognitive impairment. Assessment using the Mini-Mental State Examination and other testing methods can assist in making a determination of whether the patient can safely discharge home alone or if he or she will require some level of supervision in the home. See Chapter 10 for further discussion of cognitive assessment.

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