Dr. Justin Liu, MD
Thoughts on the Groundbreaking 2016 AHA/ASA Stroke Rehabilitation Guidelines
Posted on May 27th, 2016

In the new era of bundled healthcare payments, various healthcare systems nationwide are constantly trying to cut spending. As a direct result of this, we are seeing a massive shift in what care options patients are being directed to when they are not well enough to go immediately home from an acute hospitalization. Skilled Nursing Facilities in particular have seen a massive boom in business growth. This is attributable to the fact that many healthcare systems have been operating under the assumption that Skilled Nursing Facility Rehab is essentially the same as Acute Rehab…so why bother at all with the costlier Acute Rehab option. Despite the tremendous inaccuracy of this assumption, healthcare systems seem to have no issue operating under this mentality due to the perceived cost savings. The true repercussions of these decisions however ultimately comes at the expense of patients.

With the recent increased channeling of stroke patients to Skilled Nursing Facilities, the American Heart Association/American Stroke Association (AHA/ASA) has recently issued official guidelines for the first time on rehabilitation after stroke. Published in Stroke on May 4, 2016, the post-stroke guidelines call for intensive, multidisciplinary inpatient Acute Rehab treatment. These AHA/ASA guidelines have already been wholeheartedly endorsed by the American Academy of Neurology, American Academy of Physical Medicine and Rehabilitation, American Physical Therapy Association, American Occupational Therapy Association, American Society of Neurorehabilitation and the American Congress of Rehabilitation Medicine.

Up till now, the AHA/ASA had previously been more focused on the medical management of acute stroke. The AHA/ASA however felt it needed to formally issue new guidelines since it has found clinically significant level 1A evidence that inpatient Acute Rehab has a very clear, beneficial impact on clinical outcomes. The AHA/ASA also has come to the realization that many professionals involved in stroke care may not have been aware of this before. Through publication of detailed guidelines, the AHA/ASA is trying to encourage greater efforts to help make these beneficial interventions happen on a more global level.

The AHA/ASA Stroke Rehab guidelines specifically state that a multidisciplinary team effort is required and this is most easily delivered at an inpatient Acute Rehab facility. Given this, the new guidelines recommend that patients should be admitted to such a facility after a stroke. Based on a mixture of evidence and consensus, the foremost recommendation with Level 1A evidence includes the following:

• Inpatient rehabilitation facilities produce better outcomes than nursing homes.

Dr. Carolee Winstein, the lead author of the guidelines has explained that patients would receive at least 3 hours each day of specific rehabilitation tailored to their needs by a dedicated coordinated team of professionals. This would include physical therapy, occupational therapy, speech therapy, medical management, and a visit from a social worker, whereas at a nursing home the intensity of rehabilitation is normally lower and there is less of an emphasis on recovery, with the focus more on maintenance and medical management.

Dr. Winstein further comments, "There is considerable evidence that patients benefit from the team approach in a facility that understands the importance of rehabilitation during the early period after a stroke. So if relatives are trying to decide what type of establishment would be best for aftercare for a patient following a stroke, then they should choose an inpatient rehabilitation facility if possible.”

The guidelines however point out that 2006 Medicare data showed that only 58% of stroke patients were referred to any post-acute care. Through its new guidelines, the AHA/ASA hopes to educate patients, medical providers and healthcare systems to help promote increased utilization of inpatient Acute Rehab facilities as the recommended standard of care for post-stroke rehabilitation.

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