Post on 05-Jan-2016
transcript
Vertical Strategic Planning for Stroke Care
in PM&RRandie Black-Schaffer, M.D.
Department of Physical Medicine and Rehabilitation,
Harvard Medical School, Boston MA
I have no financial relationship with a
commercial entity producing healthcare-related
products or services.
Vertical Strategic Planning at the AAPMR
• 2011 ‘Positioning the Specialty’ summit– Drill down on specific areas of care vs. addressing
in aggregate– Move away from ‘horizontal’ planning to a
‘vertical’ approach
• 2012-13 clinical conditions identified and prioritized by Board of Governors
• 2013 Stroke and Spine pilot groups meet • 2014 VP Stroke and Spine Taskforces formed
Vertical Planning for Stroke Rehabilitation AAPMR taskforce
• Randie Black-Schaffer, MD (Chair) Spaulding Rehabilitation Hospital/Harvard Medical School, Boston
• Joseph Burris, MD (Chair, Pathways subcommittee) University of Missouri, Columbia
• Steven Flanagan, MD NYU Langone Medical Center, New York• Darryl Kaelin, MD Frazier Rehabilitation Institute/University of Louisville, Kentucky
• Joel Stein, MD Columbia University Medical Center/NY-Presbyterian Hospital/Weill
Cornell Medical College, New York City
Vertical Planning Concept
Stroke SpinePractice
LegislationAdvocacyEducation Communications
Vertical Planning for Stroke
• Position the specialty to adopt a pivotal role in providing post-acute care for stroke patients
• Develop initiatives to improve post-acute stroke care and enhance the role of PM&R in stroke care
• Harness the resources of AAPMR to help accomplish these goals
VP -Practice & Advocacy
1. Develop an AAPMR consensus statement on optimal post-acute care pathways for stroke patients - Stroke VP Pathways Task Force
2. Develop innovative practice models for physiatrists caring for stroke patients
- Practice Preparedness Committee
3. Work toward inclusion in stroke national care guidelines of standards for care throughout the initial episode of care and beyond. – Clinical Practice Guidelines Committee
VP - Education
1. Create knowledge/practice/regulatory tools to help physiatrists care for patients in all post-acute settings
– CME – CME, Program Planning Committees– SNF Medical Director Certificate Program – Practice
Preparedness Committee
3. Create educational tools for external stakeholders - Public and Professional Awareness Committee (PPAC)
2. Promote residency training in all post-acute settings - AAP, ACGME
VP - Communication
1. Build awareness within PM&R of recommended patient pathways and practice options – AAPMR website, publications, CME
2. Build awareness across related specialty organizations, e.g. ASA, AAN, of these patient pathways for post-acute stroke care – member relationships, PPAC
3. Educate the public about the post-acute care continuum and physiatry’s role in assuring optimal care for stroke patients across the continuum - Communication resources of the Academy
1. Stroke Rehabilitation Consultation in the Neuro Intensive Care Unit
2. Skilled nursing facility stroke rehabilitation
3. Long-term outpatient management
Physiatry in the Neuro ICU– Early Mobilization– Contracture avoidance– Eval and management of Critical Illness
myopathy/polyneuropathy– Use and timing of neurostimulants– Sleep/Wake cycle management– Neurogenic bowel/bladder– Spasticity management– Assessment of rehabilitation candidacy
Physiatry in SNF Rehab• 6-7% of pts in SNF rehab are there for stroke
(Dobson/Davanzo 2014)
• 5% have a Physiatry visit (Kramer 1997)
• CMS SNF requirements: – Skilled therapy 5x/wk – no time requirement– MD visit minimum q 30 days, and as ‘medically
necessary’– RN present in facility 8hrs/day
Value added by PM&R for stroke patients in SNF Rehab
Spasticity/hypertonicity management Pain management Orthotics and assistive devices Education and training for patient and caregivers Consultant to rehabilitation therapists Adjustment and mood disorders Bowel/bladder Skin integrity Consultant to nursing staff Assistance with goal of community discharge
Challenges for PM&R in SNF Rehab
• Nursing, therapy, MD staffing• Therapy equipment• Team process
– Assessment – MDS at Day 5, Day 14, Day 30, Day 60, and Day 90 to determine RUG group
– Care plan, Discharge plan
• Ancillary services often less available• Consultant vs. Attending vs. Medical Director
Physiatry in Longterm Outpatient Stroke Management
• 4.6 million community stroke survivors in US.
Brønnum-Hansen et al. Stroke. 2001;32:2131-2136
Patients 65 or older at time of stroke
Observed survival after a first-ever ischemic stroke (heavy line) or TIA (thin line) and expected survival (dashed line) based on the age- and sex-matched Italian population.
Carmine Marini et al. Stroke. 1999;30:2320-2325
Copyright © American Heart Association, Inc. All rights reserved.
Longterm OPD PM&R Management of Stroke Sequelae
• Pro-active management of:– Spasticity– Pain– Function – Orthotics/Assistive devices/DME – Rehabilitation therapies– MSK complications
• Wellness – exercise, weight, diet
Physiatry Challenges in the OPD
• Many issues – too little time!• Lack of clear standards of care for long term
management of stroke sequelae• Opportunity for Telehealth visits?
Thank you! rblackschaffer@partners.org
Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston MA