JOURNAL OF THE AMERICAN GERIATRICS SOCIETY Copyright © 1975 by the American Geriatrics Society
Vol. XXIII. No.2 Printed in U.S.A.
Evaluation of a Multidisciplinary Care Program for Stroke Patients in a Day Care Center" CLAUDE OSTER, DOt and WENDY H. KIBAT, BS**
Rehabilitation Center, Martin Place Hospital, Madison Heights, Michigan ABSTRACT: With funds received by the Rehabilitation Center at Martin Place Hospital East from the Michigan Association of Regional Medical Programs, a Rehabilitation Day Care Center was established. Initially it was called the Stroke Day Care Center (SDCC). Its purpose was to provide comprehensive care to patients with disabilities due to stroke and related diseases according to the "day at the hospital, night at home" concept. A complex of medical and allied services was fumished, based upon the patient's attendance at the SDCC from one to five days a week. The goal was to promote for the patient an earlier retum of functional, vocational, social and home activities by effectively providing him and his family with multidisciplinary care. In this SDCC program the main emphasis was on testing the feasibility of lowering the cost of stroke-patient care by: a) shortening the hospital stay; b) reducing the need for in-patient care in facilities for non-acute illness; c) shortening the stay in extended care facilities; d) returning younger stroke victims earlier to the labor force; e) identifying the number of stroke patients who could live at home if provided with a modified day care program; and f) assessing the need for purely recreational and social activities in future programs. The evaluation was based on a comprehensive study of 108 patients during the period February 1972 to June 1973. This project is offered as a model for the development and expansion of rehabilitation-recreation day care centers for the handicapped of all ages. The Stroke Day Care Center was instituted in February 1972 by the Rehabilitation Center at Martin Place Hospital through the Michigan Association of Regional Medical Programs grant No. 71-7-5. Many programs, especially those supported by Medicare and Medicaid, focus on the use of institutional care, which over the years has been demonstrated to be costly, traumatic, and
destructive to continuing family relationships and independent functioning. The program at Martin Place Hospital was designed to allow the family unit to remain intact while providing comprehensive care for patients with disabilities due to stroke and related diseases. Care was provided during the day by the Center, and during the evening and night by the family. In many cases the patients were transported to the Center in a modified bus or "strokemobile" operated by the Center. The primary goal was to provide the patient and his family with effective multidisciplinary care involving the family physician and the hospital medical staff with their specialties of rehabilitative medicine, internal medicine, cardiology, neurology, social services, physical and occupational therapy; speech therapy, nutrition, and vocational counseling. This team care
* Presented at the 31st Annual Meeting of The American Geriatrics Society, Royal York Hotel, Toronto, Canada, April 17-18, 1974. t Assistant Clinical Professor, Michigan State University; Director, Rehabilitation Center, Martin Place Hospital. ** Program Development. Rehabilitation Center, Address for correspondence: Mrs. Wendy H. Kibat, Administrative Assistant, The Rehabilitation Center, Inc., 877 S. Adams, Birmingham, MI 48084. 63
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was implemented to promote an earlier return to the patient of functional, vocational, social and home activities. In recognition of the developing pattern of overutilization of institutional long-term care for the impaired and chronically ill elderly, the Day Care project was applied to the problem of reducing health care costs for stroke patients. The specific goal was to test the feasibility of lowering the cost of providing stroke care by establishing a Rehabilitation Day Care Center for stroke patients, aimed at: a) Shortening the hospital stay. b) Reducing the need for care in facilities for non-acute illness, e.g., nursing homes. c) Shortening the stay in extended care facilities. d) Earlier return of younger stroke victims to labor forces. e) Identification of the number of stroke patients who could still live at home if provided with a program of modified day care (not hospital operated). f) Assessment of the need for purely recreational and social group activities in future programing BACKGROUND Martin Place Hospital East, where the Stroke Day Care project was located, is a 269-bed community hospital offering general medical and surgical services to the Detroit Metropolitan area. An older facility, Martin Place West, with 154 beds, is a major source of health care for the Northwest Detroit area. Both hospitals have a common administration and a single medical staff of 219 osteopathic physicians. Martin Place Hospitals have had significant achievements in stroke care. A 20-bed unit for the care of patients in the acute phase of stroke was established at Martin Place East Hospital in 1970. That unit is closely associated with the intensive care unit to facilitate a sharing of specialized personnel and specialized equipment (e.g., for cardiac monitoring, electroencephalography and echoencephalography). Once the medical condition of the stroke patient becomes stabilized, he is transferred to the adjacent stroke care unit. The hospital is staffed with specialists in the disciplines required for the delivery of care during the acute phase of stroke, including internal medicine, 64
neurology, neurosurgery, vascular and cardiac surgery, and physical medicine. An area was designated where inpatient physical therapy was readily available to patients admitted to the Acute Stroke Unit. The Rehabilitation Center provides physical medicine and rehabilitation services, inclusive of physical therapy, occupational therapy, speech therapy and psychologic counseling and evaluation to the hospital. Stroke care procedures and policies were jointly developed with Stroke Centers in acute stroke programs, in association with base center at Wayne State University. Since 1971 a Stroke Coordinating Committee has met regularly; it is composed of a physiatrist, neurologist, internist, nurse supervisor, rehabilitation nurse, social worker, physical therapist, occupational therapist, psychologist, public health nurse, speech therapist, and a representative of the Visiting Nurse Association. In their meetings the Committee members develop standards for the treatment of stroke patients, and periodically evaluate each patient in the Acute Stroke Unit and the therapy he is receiving. The Stroke Committee also trains hospital personnel in the special techniques required for proper care of stroke patients, and has developed and published a manual for this purpose. In summary, Martin Place Hospital had developed, at its own expense, an effective Acute Stroke Unit which had successfully functioned for over two years. This unit served as an excellent resource of experience. Personnel and patients had developed the innovative Day Hospital project known as the Stroke Day Care Center, aimed at reducing the acute phase of stroke, speeding the rehabilitation of stroke patients, and thereby reducing the cost of stroke care. THE STROKE DAY CARE CENTER (SDCC) The acute phase of a stroke patient's hospitalization is followed by a period of intensive rehabilitation and recovery of lost function to the maximum degree possible. Yet a point often is reached where self-care is adequate, but major rehabilitation regimens are still required and best carried out at a rehabilitation center or clinic. It is at this stage in the recovery of the patient that a Day Hospital program can
PROGRAM FOR STROKE PATIENTS IN A DAY CARE CENTER
make its greatest contribution. A day hospital provides the opportunity to send the patients home sooner and to reintegrate them with their family and community life, while still providing a full range of needed rehabilitation therapy. The Stroke Day Care Center (SDCC) was an outpatient facility immediately adjacent to Martin Place Hospital East. It provided rehabilitation services to stroke patients after their discharge from an acute stroke unit or a cooperating extended care facility. The services provided were physical medicine, occupational therapy, speech therapy, psychologic and vocational counseling, social services, recreation, transportation, hot meals, and help with the activities of daily living. More detailed vocational training in conjunction with or following the SDCC program was arranged through the working representative of the Division of Vocational Rehabilitation assigned to the Day Care Center. During a patient's participation in the SDCC, intensive direction was given, in cooperation with the Visiting Nurse Association and the Public Health Department, to planning for family needs and modification of the home environment to fit the patient's deficit. Admission to the SDCC depended upon criteria developed by the Stroke Committee. In general, all patients considered for transfer to an inpatient rehabilitation center or to an extended care facility (ECF) were candidates for admission to the SDCC. Patients from an ECF who no longer required intensive 24-hour supervision but still were unable to function without ancillary rehabilitative services were also candidates for the program. No patient was considered who was totally bedridden, comatose, confused or demented. All applicants for admission were reviewed by the rehabilitation team with respect to their potential for benefit from the program and the ability of the patient's home to care for him in the evening and at night. In line with the program's objective of returning younger stroke victims to the work force more efficiently, top priority was given to those referrals considered to be re-employable. When possible, patients were transported to and from the facility by family or friends. However, an integral and key part of the program was the use of a "strokemobile." This modified van, equipped for wheelchair transfer
and staffed with specially trained drivers, transported an average of 30 patients per week to and from the center. Upon arrival at the center the patients were placed in a course of therapy determined by their individual rehabilitation needs. Therapy procedures were performed intermittently throughout the day, allowing time for rest, socialization, recreation and intellectual pursuits. The physical plant consisted of basic kitchen facilities used for training in activities of daily living and for low-volume center entertaining; a large community room for dining, socialization and group activities; a gymnasium for therapeutic activities; a rest area with two fold-away beds; a workshop for occupational therapy and hobby cultivation; a speech office; an examining room; a staff conference room; a coordinator/secretary space; a reception area; and an area for outside gardening and activities. The center in total occupied 8,000 square feet. The staff comprised a team composed of a program coordinator, a registered occupational therapist, a registered physical therapist, a speech pathologist, a psychologist, a nurse, a secretary, a transportation technician, a social worker, a transportation orderly, and two aides. The medical director of the rehabilitation center was the team leader and physiatrist for the SDCC. Census. From February 1972 until June 1973 the Stroke Day Care Center was operating at a mature and stable census level, as follows: I. Participants: 49 females} total, 108 59 males II. Age of participants: average age, 47 years range, 25-81 years III. Diagnosis: 99 cerebrovascular accidents (CVAs) 9 "other" categories IV. Treatment days; length of stay: total treatment days, 3476 average number of treatment days per patient, 32.25 range, 1 to 163 days V. Day Care referrals culminating in Center admissions: Direct hospital referrals from: Detroit Osteopathic Hospital Martin Place East
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Martin Place West Bi County Hospital Non-hospital referrals from: Visiting Nurse Association County Health Departments (Wayne, Oakland, Macomb) Private physicians American Heart Association County Social Services Departments (Wayne, Oakland, Macomb) Multiple Sclerosis Society Jewish Family and Children Services Catholic Family Services Metropolitan Stroke and Aphasis Club Office of Economic Opportunity Miscellaneous, inclusive of family, friends, and self-referrals. From this experience we drew our conclusions with regard to the project's objectives. OBJECTIVES OF THE SDCC PROGRAM
Objective No.1 To test whether the SDCC can reduce the length of hospitalization for the stroke patient. A comparative study (comparison "t" test) without the SDCC was performed by examining the hospital records of all stroke patients one year before the day care project was launched, in terms of the SDCC admission criteria. In terms of hospital days, the difference was determined between the hospital discharge time table and that imposed by the SDCC criteria. Also determined was the total length of the care period, through discharge, after one year of the program's operation. The data did not indicate that length of stay had been significantly reduced by the Day Care project. However, a slight reduction was obtained. The statistical validity of the comparison data may have been impaired by the following factors: 1. Size of the sampling group. The SDCC, being a single innovative program, did not offer a broad comparison base. 2. Small number of eVA cases. The base data on either the Martin Place Hospital patients or on the patients of the PAS length-of-stay study involved only a relatively small number of cases in the category of cerebrovascular accidents (CVA). 3. Wide range of disease severity. CVA en-
compasses a wide range of disease severity which, even in our small sample, resulted in lengths of stay ranging from 5 to 52 days in one time period. Therefore, comparatively large differences from the mean were not statistically significant. 4. Lack of notable success in efforts to increase the number of patients admitted to the SDCC directly from general hospitals and to encourage doctors to discharge their eligible patients sooner. Some reasons for the relatively small number of direct referrals were: 1) patients discharged from general hospitals or ECFs had difficulty obtaining transportation to the Center and living in areas on the "strokemobile" waiting list; and 2) some patients and their families were reluctant to allow the stroke victims to participate in an outpatient program "so soon after a stroke."
Objective No.2 To determine the cost reduction resulting from the SDCC program. Since any statistically demonstrated cost reductions were directly dependent upon reductions in the length of hospital stay, the inevitable length-of-stay problems were compounded by using the analytic data in the calculation of the cost. However, there seemed to be a slight cost reduction for the average SDCC patient on a per diem basis. Reduction of hospital care costs has long been a major concern of state and national organizations for health care and of third-party providers. For the patient with an acute illness, the longest period of hospital stay is spent in the rehabilitation phase, receiving services which could be provided on the day-hospital level of medical care. The SDCC reduced the length of hospital stay, returned patients to their family units and, when feasible, restored them to a contributing role in the national economy. In 1972 there were 40 million people within the United States who were physically disabled to some degree. Many of these people were in an age and disability group that made them eligible for rehabilitation and return to employment. When this could be accomplished, the benefits to society were enormous. For example, the first-year earnings of the 134,859 persons rehabilitated during 1965 through the
PROGRAM FOR STROKE PATIENTS IN A DAY CARE CENTER
state-federal rehabilitation program contributed an estimated $297 million to the economic wealth of the nation. Yet, this program affected only 25 per cent of the persons who required rehabilitation that year. The SDCC, because it removed the patient from institutional dependency sooner and constituted an alternative to long-term institutional care, referred 20 of its participants to Vocational Rehabilitation Services as candidates appropriate for re-employment.
Objective No.3 To test whether the SDCC can reduce both the need for and the length of stay in extended care facilities (ECFs) Although professional support of this program was recognized by extended care facilities in the area, only a few patients were discharged from those facilities into our program. However, among the 33 patients transferred directly to the SDCC from acute-illness facilities, only 1 was discharged from the SDCC as a referral to an ECF. It would seem desirable that all hospital patients with CVA should go through a utilization review by a review team that could recommend a day hospital at the appropriate stage of the stroke recovery process, and that this recommendation should be followed as part of standard medical management procedure. Continuous efforts should be made to orient the medical profession as well as the patient's community to the concept of day hospital care as an intermediate step between the care of acute illness and functional independence from medical services. Objective No.4 To provide a model of SDCC that can guide similar efforts elsewhere within the region. A continuing effort has been made to gather and refine objective criteria for admission and discharge of stroke patients in a day care center, to serve as a model for others. All patients considered for transfer to an ECF also should be candidates for admission to a Stroke Day Care Center if they do not fall into the categories of totally bedridden, comatose, confused, or demented. All applicants for admission should be reviewed by a team to determine the patient's potential for rehabilita-
tion, ability of the home to care for him in the evening, night and weekends, and the patient's potential for re-employment. A stringently objective list of criteria for SDCC admission cannot be developed. In this type of evaluation, in which medical, social and economic variables interplay, the physician in charge of the daily operation of the Center should keep all options open. Admissions and discharges should be based essentially on his own professional judgment and that of the involved paramedical staff, in a detailed evaluation of each patient as an individual. In future day care endeavors a more comprehensive transportation network should be established. Although the Center offered transportation, the strokemobile could not accommodate the needs of the many potential day care participants dispersed throughout the Detroit Metropolitan Area. Furthermore, in many cases, even if private or public transportation had been available, it could not functionally accommodate wheelchair patients.
Objective No.5 To assess the need for an environmental enrichment program The SDCC program was discharge-oriented. Its objective was to admit patients as early as possible after the onset of the CVA, and to prescribe a progressive plan of treatment to restore them to their maximum psychologic, physical and intellectual competence. The ultimate objective was to help these patients achieve their rehabilitation plateau and be referred to a treatment service for continuing care designed to maintain that health status. For patients displaying vocational potential (homemaker, or re-employment in industry), appropriate planning was started by the Center through Vocational Rehabilitation Services. However, for the 108 patients who were unable to resume employment or homemaking functions but whose status reached a rehabilitation plateau, the discharges were as follows: 76 to
Community Recreation Programs (CRP) only 4 to General Hospitals (acute illness facilities) 15 to Vocational Rehabilitation Services (VRS) and CRP 4 to VRS only 67
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3 to Outpatient Departments and CRP 5 discharged for miscellaneous reasons, e.g., patient unable to adapt to the Center environment, low physical tolerance, moved from the area, or unable to continue being transported to the center 1 death. Of the 108 patients, 94 were discharged to community recreation programs. Since the existing programs operated on a one-day-a-week schedule, and no transportation was provided, their services could not fill the total needs of these patients. All patients discharged from the SDCC could have benefited from an environmental enrichment program. Moreover, some patients could have been discharged sooner if this type of program had been available. Environmental enrichment programs on a day care schedule should be provided for those patients who, although not requiring intensive care, merit full-time companionship, supervision, assistance and stimulation through intellectual, social and diversional pursuits. The program should be geared to provide an outlet for the creative and purposeful use of existing physical and mental capabilities. Of equal importance, the program would permit the patient and his family to remain intact as a household unit while retaining some individual freedom and independence by reducing the amount of time during which the patient must rely solely on family care. Additional suggested services that might be maintained on a day care level include: nutritional counseling and education regarding the preparation of special diets; assessment of nursing care needs and arranging for the indicated treatment; periodic screening for optometric and dental needs; and an information service to direct participants and their families to community resources appropriate for their medical, financial and emotional needs. The most reasonable and efficient way of enacting these recommendations would be to offer general hospital, day hospital, and day care programs in the same physical facility, employing some of the same staff and using the same sources for such services as nutrition (diet), transportation, recreation, and counseling. The cost of social and environmental enrichment services would be much less that the cost of the rehabilitation program which would be
providing multitherapeutic treatments by professionals each week. THE DUAL APPROACH - FUNDING When support from the Michigan Association of Regional Medical Programs was prematurely discontinued in June 1973, due to federal cutbacks, the Day Care Center, because of its overall success, expanded its operation to include dual day-hospital care. At that time it was decided to broaden admissions to include all persons, regardless of age, diagnosis, or degree of disability. The Center operated under this concept from July to August 1973. The charge for day care was $10 per diem. However, even though the cost of day care ($10 per diem) was significantly less than the cost of nursing-home care (average, $20 per diem), attendance dropped and the Center was forced to close. We continued to receive inquiries from prospective day care patients, but we found upon investigation that usually the persons most in need of the services were those who were least able to pay. Stroke patients are faced with long recovery periods and highly uncertain outcomes. If recovery becomes a long-term process, it often results in a great reduction of family income at a time when financial obligations are rising. The advantages of day care over nursinghome care are not only economic. More often than not, the family feels guilty about placing a relative in a nursing home, and the patient in turn may feel rejected. With day care, the disabled or elderly person continues to live at home with his family. At the same time, family members are free to work during the day knowing that their relative is under the care of a professional staff. In most cases, social, mental, physical and financial benefits are derived by the day care patient and his family. The Day Hospital concept is not new, and indications from our pilot program have shown that the need is well established. Nevertheless, to date, most government funding for day care has been on a research and demonstration basis. No operating funds are available for continuation of the full spectrum of program services on a continuing basis. At present there is only partial reimbursement for a limited number of services (physical therapy, speech therapy, and podiatry) which might be performed as part of a day hospital program. Such coverage is through the use of outpatient benefits
PROGRAM FOR STROKE PATIENTS IN A DAY CARE CENTER
normally covered through existing insurance plans [including Blue Cross, Title XVIII (Medicare, Part B) and Title XIX, Medicaid]. However, both interest and reimbursement possibilities have been developed by the Medical Services Administration of Social and Rehabilitation Services for the support of day programs under Title XIX. In April 1973 a statement was issued from that office advising the Regional Offices of Social and Rehabilitation Services with regard to interpreting day treatment and mechanisms for reimbursement to States seeking to provide those services as part of their Medicaid programs. States were given the authority to reimburse for day hospital and day care projects that provide medical,
health, and health related services. To qualify, these programs must be operated by a Statelicensed or approved hospital, or an organization recognized as a clinic under State law and/or regulations in States which include clinic services in their State Plans. Although the federal government has encouraged the Day Care concept, the primary responsibility for administration of the Medicaid program lies with the States. Until the States include such services in their State plans, the mechanisms for third-party support of a long-term endeavor remain elusive. At present, in the state of Michigan, no day care services are being funded by the Michigan Medicaid program.