Early supported hospital discharge and continued rehabilitation at home after stroke

Sammanfattning: This thesis, based on studies conducted in the South West Health District of Stockholm County sought: 1) to explore and compare the behavior of patients and therapists during stroke rehabilitation sessions in the home and in the hospital; 2) to describe a program of early supported discharge and continued rehabilitation at home for patients with moderate neurological impairments after stroke; and 3) to evaluate the effect of the program in terms of patient outcome, resource use and cost of health care in comparison with routine rehabilitation. Eighty-three patients-continent, independent in feeding and mental function within normal limits, with impaired motor capacity and/or dysphasia 5-7 days after acute stroke-were included in a randomized controlled trial; 41 were allocated to early supported discharge and continued rehabilitation at home (HRG) and 40 to routine rehabilitation (RRG). All patients received initial care and rehabilitation in the stroke unit of the Department of Neurology of Huddinge University Hospital. Follow-up of patient outcome 3, 6 and 12 months after stroke included mortality, motor capacity, aphasia, activities of daily living, social activities, perceived dysfunction and self-reported falls. Patient satisfaction with health care was assessed at 3 months after stroke. Resource use over 12 months included inpatient hospital care, outpatient health care, use of health-related services in the municipality, informal care, and cost of health care. Observations, semi-structured interviews and documents were used to explore differences in the behavior of therapists and patients during rehabilitation sessions at home and in the hospital, as well as to describe the content and implementation of the intervention program. Support and continuity of rehabilitation throughout the levels of care-from the stroke unit to the patient's home-were provided by a multidisciplinary outreach team, from which one therapist was selected as case manager. The early supported discharge was aimed to coincide with the attainment of independence in toileting. The intervention program entailed an individualized rehabilitation program-varying in duration (mean=14 weeks, range 4-29 after hospital discharge), frequency of home visits (mean 12 visits, range 3-3 1) and content- based on the patient's needs, and planned and carried out in partnership between the patient and the therapist. Face-to-face contact with the patient, which constituted 54% of the total of 1093h of the home rehabilitation program, was spent in dialogue and training. Self-directed training was performed an average of 1 1/2 h a day per patient. The intervention included counseling and guiding the spouse when needed. In the RRG 20 patients were discharged from the stroke unit to their homes and 18 were transferred to departments of geriatrics or rehabilitation, where they had at least 1142 contacts with members of the rehabilitation staff. The home of the patient was found to provide an environment more amenable than the hospital for a stroke rehabilitation session whose aim was promoting active patient participation and shared responsibility for the rehabilitation process. There were 2 losses and 1 death in the HRG, and 3 deaths but no losses in the RRG. At 1 year after stroke 77 patients-39 in the HRG and 38 in the RRG-were followed-up. There was no difference in patient outcome. By multiple regression analysis intervention was suggested to have a significant effect on independence in activities of daily living. At 3 months patient satisfaction in the HRG was, with regard to participation in planning the rehabilitation, significantly better than in the RRG (P=0.021) and at least as good in all other domains. During the first year after stroke a significant difference in inpatient hospital care, initial and recurrent, was observed, with means of 18 (HRG) vs. 33 days (RRG)(P=0.002); while there was no difference in resource use of outpatient health care, home help service from the municipality or informal care. In Stockholm Sweden, early supported discharge with continued rehabilitation at home proved no less beneficial than routine rehabilitation for patients with moderate neurological impairments after stroke. The average cost of health care for 5 patients in the HRG during I year was similar to that for 4 patients in the RRG.