Australian Stroke Coalition
Assessment for
Rehabilitation:
Pathway and DecisionMaking 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
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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)
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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 DecisionMaking 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?
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.:
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)
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)
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/cleaning
Serviced cars and did majority
of gardening
Y – incorporate raised bed
gardening tasks in rehab
Vocational
Accountant
Y – incorporate bookkeeping 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
Need for
intervention?
Y/N and if yes, plan?
Environment
Pre-stroke (note barriers and facilitators)
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 respite
One 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 – accessible
Accountancy 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 institution
2. (Conduct audit of current practice)
3. Hold formal education session/s to become
familiar with details and processes
4. 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 Network
2. Methods for initial project
3. Pilot results
4. 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………..
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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
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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:
104
articles
* Funding from
Bayer Australia
National survey of
current practice
Systematic
search of the
literature*
Expert working
groups
52
sites
40
great
minds
Australian Stroke Coalition
Piloting – in sites in most states (n=6)
Positives:
• ensured clear and accountable decisionmaking,
• focused on the person with stroke and
their family (not services)
• Increased involvement of all stroke team
members
• More wholistic as based on the ICFWHO 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 – susan.hillier@unisa.edu.au
or
Leah Wright – lwright@strokefoundation.com.au