How to Find the Best Care After a Stroke
About 800,000 Americans suffer from strokes each year. Some of them are left with temporary physical impairments that can last weeks or months. Others may be faced with permanent disabilities. Studies show that stroke rehabilitation helps in even the most severe instances. But there has been little consensus on the best rehabilitation approaches—until now.
In May the American Heart Association and the American Stroke Association released the first-ever guidelines for stroke rehabilitation, which call for intensive multidisciplinary treatment, in the journal Stroke.
“Evidence-based recommendations such as these offer invaluable guidance to healthcare professionals,” says Peter V. Rabins, M.D., M.P.H., a professor at the Erickson School of Aging, University of Maryland, Baltimore County, and founding director of geriatric psychiatry at Johns Hopkins University School of Medicine in Baltimore. “They can also help guide patients and their families in getting the best care possible after a stroke.”
Acute event, chronic condition
A stroke disrupts the flow of oxygen-rich blood to the brain, because either an artery becomes clogged (an ischemic stroke) or a blood vessel in the brain ruptures (a hemorrhagic stroke). Deprived of oxygen, brain cells die.
The guidelines make clear that a stroke is best thought of as a chronic condition and not just an acute event. Recovery can often continue for years.
For the stroke patient, rehabilitation begins in the acute hospital setting, and a treatment plan will be designed before you’re discharged. But before you leave, you should participate in a structured fall-prevention program. It should include information about:
Making your home as safe as possible (removing throw rugs and increasing lighting, for instance);
Medication side effects that may affect balance; and -How to use any assistive mobility devices like walkers, wheelchairs, and canes.
Intensive care is best
Foremost in the new guidelines is the strong recommendation to choose an inpatient rehabilitation facility over a skilled nursing facility for after-stroke care. Inpatient rehab facilities must provide at least three hours of daily rehabilitation. The facilities can also offer 24-hour nursing care and daily doctor’s visits. It can be a stand-alone facility or a unit located within a hospital.
Inpatient rehab is covered in part by Medicare, but the remaining out-of-pocket costs may prove prohibitive for some. The availability of local facilities, especially in rural areas, may also be limited.
Skilled nursing facilities, in contrast, are required to have a nurse available for only eight hours a day. They’re better equipped to care for stroke survivors who may not be able to reach full or partial recovery. Medicare covers a stay of up to 100 days.
As long as you’re able to take part in stroke rehabilitation and have access to a rehab center, you should be transitioned to an inpatient rehabilitation unit. If your acute-care hospital team refers you to a skilled nursing facility, insist—or have a loved one insist—on transitioning to an inpatient rehabilitation facility instead.
“Advocate for referral to a certified inpatient rehabilitation facility,” Rabins says, “where a coordinated, multidisciplinary team of stroke experts can tailor interventions to meet your needs and help you achieve your full potential. Studies show that patients discharged to an inpatient rehabilitation setting have greater rates of functional recovery and are more likely to return to community living than those who enter a skilled nursing facility or a nursing home.”
A medical team at an inpatient rehabilitation facility brings together experts in neurology, rehabilitation, occupational and physical therapy, speech and language therapy, psychology, nursing, social work, and nutrition. What’s more, the AHA and ASA emphasize the importance of including family, friends, and caregivers on the team. Care coordination and communication among all team members are essential to a patient’s successful outcome.
According to the guidelines, specific features of an inpatient stroke rehabilitation facility should include:
Intense repetitive training to improve mobility and practice tasks such as sitting, standing, walking, and climbing stairs.
Balance training and general strengthening activities.
A customized cardiovascular exercise program, which can be adapted for at-home use upon discharge.
An enriched environment to promote cognitive activities, with access to computers, books, music, and virtual reality games.
Eye exercises and speech therapy.
Nutrition screening, particularly to ensure patients are getting enough calcium and vitamin D to reduce fracture risk.
Opportunities for an open discussion coordinated with patients and their partners about sexuality. Sexual function is commonly affected by stroke, but patients are often reluctant or embarrassed to discuss these issues spontaneously.
Although disabilities can persist and sometimes be lifelong, people often regain much of their independence.