Ontario Stroke Evaluation Report 2018: Stroke Care and Outcomes in Complex Continuing Care and Long-Term Care

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Each year, approximately 1,300 individuals in Ontario are admitted to long-term care (LTC) within 180 days of an acute care hospitalization for stroke or transient ischemic attack (TIA).  To better understand the sociodemographic characteristics and burden of care for stroke survivors admitted to LTC, a new provincial report was released by CorHealth Ontario and the Institute for Clinical Evaluative Sciences, entitled:  Ontario Stroke Evaluation Report 2018: Stroke Care and Outcomes in Complex Continuing Care and Long-Term Care. This report provides a review of data between 2010 and 2015, and delves into the nature and extent of rehabilitation therapy and stroke best practices available to stroke survivors in these settings.

The intent of this report is to inform system planning, facilitate and advocate for system change, and identify opportunities for quality initiatives and research.

Of stroke survivors residing in LTC, key findings for 2014/15 include the following:

  • 2% were women
  • 3% required extensive assistance with activities of daily living
  • 8% were at high risk for depression
  • 4% experienced bowel incontinence and or 61.3% were reported to have bladder incontinence
  • 3% had severe cognitive impairment
  • 6% were considered to be socially engaged
  • 9% were admitted to inpatient rehabilitation prior to admission to LTC (an increase from 21.5% in 2010/11)
  • 4% did not receive any core therapies (i.e. physiotherapy, occupational therapy and speech-language pathology) and no stroke survivors received all three core rehabilitation therapies. Given that time spent in therapist-supervised core rehabilitation is calculated over a 7-day period, the median number of minutes of physiotherapy received per day was 6.4.  Only negligible amounts of occupational therapy and speech-language therapy services were provided.
  • 4% received nursing restorative care programming (a decrease from 28.5% in 2010/11)
  • 5% experienced a fall
  • 3% diagnosed with atrial fibrillation received anticoagulant medication within 90-days of discharge from acute care
  • 1% died within 6 months of admission to LTC following their acute stroke or TIA.

Also of note were the low health-related quality of life scores (mean = 0.37 out of 1) and the proportion of stroke survivors in LTC over 85 years of age, which increased from 36.1 to 40.8 per cent over the five-year period.

Conclusions from the report specific to LTC are outlined below:

  1. Stroke survivors in LTC settings have high care needs requiring extensive assistance with activities of daily living. Their low degree of social engagement and poor health-related quality of life are concerning.
  2. Rehabilitation for stroke survivors in LTC is almost exclusively physiotherapy. The time spent in rehabilitation therapy and recreation therapy per day is minimal, and access to physiotherapy and nursing restorative care in LTC has declined over time. The low health-related quality of life scores may be attributed to the limited rehabilitation, nursing restorative care and recreation therapy, and the prevalence of depression and pain.
  3. Defining the role of LTC in the stroke recovery trajectory will become more imperative as the shifting demographic is predicted to result in an increasing number of LTC admissions and increased stress on the overall health care system.

MORE: PUTTING A STROKE COACH IN EVERY PATIENT’S CORNER

This report also outlines the following recommendations specific to LTC which address changes at the system, regional and facility level:

  1. Limited provision of rehabilitation to stroke survivors in LTC warrants review of resource allocation/care models for rehabilitation therapy and nursing restorative care programming to inform an appropriate model for this setting.
  2. Regional Stroke Network Community and LTC Coordinators should advance stroke best practices and LTC staff education by:
    • Leveraging existing stroke care resources (e.g. Taking Action for Optimal Community and Long-Term Stroke Care©, Stroke Care Plans for LTC, etc.), existing technology (learning management systems, software solutions) and partnering with stakeholders such as the RNAO LTC Best Practice Coordinators.
    • Supporting specialized training of LTC staff in secondary stroke prevention and highly prevalent post stroke complications such as urinary incontinence, fall prevention, pain management, and post stroke depression.
    • Supporting LTC facilities in modifying care planning libraries to include best practice care interventions as outlined in the Stroke Care Plans for LTC (e.g., integrate the Stroke Care Plans into care planning libraries where gaps are identified).
    • Collaborating with LTC facilities to sustain current efforts and explore further innovations in fall prevention strategies and programs to promote safe mobility.

The LTC representative from your Regional Stroke Network is available to provide further information and to support quality initiatives aimed at enhancing  best practice stroke care provided to residents of Ontario LTC Homes. To access this representative within your area, please email CorHealth Ontario at info@corhealthontario.ca.

Submitted by Community & LTC Coordinators of the Ontario Regional Stroke Networks.