Stroke affects approximately 9,000 New Zealanders annually1 and in 2016/2017 there was a prevalence of 1.5% or approximately 57,000 adults.2 Stroke is the leading cause of long-term disability in the developed world3 and most people surviving stroke will require rehabilitation.4

Stroke rehabilitation should begin the day after stroke and will often need to continue following discharge from hospital.5 Rehabilitation in the community can lead to improvements in recovery in terms of regaining independence and returning to activities of daily living.4 While research has found that rehabilitation after hospital discharge is provided in most places in New Zealand, there is great variation in treatment intensity and often a significant delay in the provision of these services.6

At Capital and Coast District Health Board (CCDHB) three general community teams provide community stroke rehabilitation to patients in the area. CCDHB provides services to a population of approximately 307,250 (2016/17 estimate).7 In the Wellington catchment area (population of approximately 131,000),8 the Wellington Community Older Adults, Rehabilitation and Allied Health (WCORA) team provides rehabilitation to people with stroke aged 16 years and older. Approximately 25% of stroke patients in the region are referred for community rehabilitation, and these patients make up approximately 12% of the team’s total workload. WCORA is an interdisciplinary team with allied health, nursing and medical health professionals, however it is not a stroke-specific community team. The team delivers a five-day-a-week service during business hours, with no treatment available on weekends or public holidays, and does not provide an early supported discharge service. Rehabilitation is provided predominantly in patients’ own homes, but outpatient appointments are also available for those able to travel. The WCORA team routinely incorporates patient ‘home work’ in addition to therapy sessions, in order to increase rehabilitation intensity. However, this component of therapy time was not captured in this audit.

Guidelines vary in their recommendations for stroke rehabilitation provision in the community in terms of frequency, intensity and how soon post-hospital discharge this should commence. The New Zealand National Stroke Network9 published minimum recommended standards for DHBs in the delivery of community rehabilitation for patients with stroke. These recommendations included commencing a rehabilitation programme within seven calendar days of hospital discharge and providing three days a week of physiotherapy, occupational therapy and speech language therapy for the first four weeks, as clinically indicated. In 2018, the Ministry of Health (MOH) introduced a community rehabilitation indicator which states that 60% of patients referred to the community rehabilitation team should have a face-to-face contact within seven calendar days of hospital discharge.10 Stroke rehabilitation practice guidelines from Canada11 state that therapy for patients with stroke should be provided for at least 45 minutes a day per discipline required, two to five days per week for at least eight weeks. The Healthcare for London stroke rehabilitation guide12 recommends patients are contacted by the community team within twenty-four hours of discharge from hospital, assessed within three days of discharge and that treatment is commenced within seven days of assessment. The guideline also recommends three sessions per week of community physiotherapy, occupational therapy and speech-language therapy, as clinically indicated, for the first four weeks and suggests that rehabilitation should be provided on an ongoing basis to allow patients to meet their goals.

Aims

This service audit set out to determine the current state of stroke rehabilitation practice within the WCORA team and to compare this against best practice guidelines.

This audit aims to determine how quickly following hospital discharge patients with stroke are seen for community rehabilitation, and the amount and number of contacts of rehabilitation they receive within the first four weeks and three months of hospital discharge. In addition, patient satisfaction with the community stroke rehabilitation service will be assessed.

Methods

Study design

Fifty consecutive patients with a new diagnosis of stroke referred to the WCORA team for rehabilitation were included in this prospective audit, commencing in June 2016. Patients were identified from the team’s referral register. The paper-based data collection tool was placed in the front of the patient’s community medical file. Clinicians (including physiotherapists, occupational therapists, speech-language therapist, liaison nurses, social workers and rehabilitation assistants) documented where treatment occurred (eg, home, workplace, outpatient setting) and the amount of time spent treating each patient for the first three months they were involved or until discharge, whichever occurred first. The WCORA team is a goal-oriented service, and patients are discharged once their therapy goals are met. Clinicians were asked to only document treatment time (not assessment) during their sessions.

On completion of treatment, patients who were still alive were sent a seven-question survey to assess their satisfaction with the amount of treatment received and the location in which they received it. They were also asked to indicate whether they would come into an outpatient clinic if more treatment could be provided in that setting. The survey was designed to be aphasia-friendly so that those patients with a speech or language disorder could complete the survey if they wished. As this was a service audit project assessing the current state of practice, it was determined that formal ethics review was not required.

Data analysis

Simple data summaries (mean, SD, median, IQR, minimum and maximum) were calculated using Microsoft excel.

Results

Fifty patients were included in the audit between June 2016 and March 2017. For the amount of treatment received and the treatment location, we had 46 sets of complete data at the end of the audit period. One patient died before completing the audit period and notes for three people were not able to be located. The average (SD) number of days from hospital discharge until first appointment with the community team was 11.5 (7.0) days (median 10; IQR 6.3–14.8), while the average (SD) number of days until first treatment session was 13.9 (9.1) days (median 11.5; IQR 7–20). Seventeen of the 46 patients (37%) were seen within seven calendar days of hospital discharge. Twenty-nine of 46 patients (63%) received treatment as well as an assessment at their first appointment.

Patients received in total an average (SD) of 4.3 (3.4) visits from all required disciplines combined during the first four weeks after hospital discharge (median 3; range 0 to 15) and a total of 11.6 (10.3) visits during the first three months or until discharge from the community team, whichever occurred first (median 7.5; range 1 to 38). Table 1 presents the number of rehabilitation sessions and amount of rehabilitation received per week in the first four weeks following hospital discharge and the total received throughout the audit period (three months post-hospital discharge or until the patient was discharged from the WCORA, whichever occurred first). Zero hours indicates that the patient received an assessment, but no treatment was provided. Nineteen of the 46 (41%) patients were still receiving treatment from one or more members of the WCORA team three months after hospital discharge. Sixteen of the 46 (35%) patients received only one or two sessions before being discharged, based on their clinical need.

Table 1: Number of rehabilitation sessions and amount of rehabilitation received per week.

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*In some cases this was <12 weeks if goals were achieved sooner.

Forty-nine patients were still alive at the end of the follow-up period and were sent a survey. Of these, 18 (37%) responded. Of the 18 patients who responded to the survey, 11 (61%) reported receiving treatment at home, one (5.5%) in the outpatient clinic only, five (28%) both at home and in the clinic and one (5.5%) did not respond to the question. Eleven of the patients (61%) who responded to the survey indicated they “completely agreed” or “mostly agreed” that their preference was to be seen at home. Two of the patients (11%) indicated that they did not have a strong preference on the location of their treatment. In contrast, 10 (55.5%) patients indicated that they “completely disagreed” or “mostly disagreed” with the statement “I would have preferred to be seen as an outpatient”. Patients who responded to the survey appeared, on the whole, satisfied with the amount of rehabilitation that they received from the community ORA team. Thirteen (72%) of the respondents completely agreed with the statement “I was happy with the amount of treatment I received”, two (11%) mostly agreed, one completely disagreed (6%) and two (11%) did not respond to the question. Five (28%) of respondents specified they wanted more treatment than they received, with four of the five (80%) indicating that they would attend a group session in order to receive additional treatment.

Discussion

This service audit set out to explore current stroke rehabilitation practice within one community-based team in Wellington, New Zealand. In line with previous research6 the audit found that for many patients with stroke there was a delay following hospital discharge in receiving community rehabilitation. Thirty-seven percent of patients were seen within seven calendar days of hospital discharge and some waited up to one month to be seen for their first appointment. This percentage falls well short of the MOH’s indicator of 60%.

Delays in community rehabilitation commencement can be attributed to either service or patient factors. From a service perspective, all referrals for the WCORA team, including those for patients with stroke, are screened as routine. There are no urgent appointments available with allied health professionals in the team and as this service is not stroke-specific, patients with stroke are not prioritised differently to other patient groups. All patients are booked into the next available appointment with the appropriate health professional. As such, the volume of referrals received by the team will have an impact on the length of time a patient with stroke will have to wait for community rehabilitation to commence. In addition, in the WCORA there is no backfill available to cover staff leave, extreme weather may result in community staff being taken off the road due to flooding (thus requiring appointments to be cancelled) and the Christmas period where, as per organisational preference, staff are encouraged to take leave and only skeleton staffing is available. Patient factors may include other medical diagnoses or events (eg, admission to hospital with another medical problem) precluding or contraindicating earlier commencement of rehabilitation. In addition, the patient may decline an earlier available appointment in favour for a day or time that suits them better. Neither of these issues were specifically captured in the current audit, but any future audit should do so to help clarify reasons for delays.

It is likely that both service and patient factors impacted on how quickly patients with stroke were seen in the community for rehabilitation following hospital discharge. Patient factors are largely outside the control of the service and are the reason why indicators are not set at 100%. Service factor delays, however, need to be addressed. One solution could be to make available an ‘urgent’ appointment each week for an allied health professional to see patients with stroke promptly following hospital discharge. As a general community rehabilitation team providing stroke rehabilitation, care would need to be taken not to disadvantage the timeliness of rehabilitation to other patient groups.

Previous research6 suggests that not only do patients with stroke often have to wait for community rehabilitation to commence, but that at the first appointment they may only receive an assessment. In this audit, nearly two-thirds of patients began their treatment in the community during their first contact with a WCORA health professional. This is important as there needs to be a seamless transition between inpatient and community services, with continuation of intensive rehabilitation for those patients with rehabilitation needs.6,13

Group therapy sessions are one method of delivering rehabilitation post-stroke. One benefit of group therapy in the community is that sessions can be scheduled in the first week after hospital discharge. This ensures a smooth transition between inpatient and community rehabilitation services and limits the break in rehabilitation for the patient.13 Group therapy may be more efficient and cost-effective, as there is a lower staff-to-patient ratio compared to individual therapy. English et al (2007)14 demonstrated that providing inpatient physiotherapy in a group setting compared to individual sessions led to a significant increase in therapy time with no increase in cost. However, in the community the provision of group, clinic-based therapy may be limited by difficulties with accessing the clinic due to transport requirements, or by having a low referral rate of patients with stroke at a particular time point.

This audit demonstrated that the intensity of rehabilitation, as well as the number of contacts patients had in the first four weeks after hospital discharge, fell well short of recommended practice guidelines.9,11,12 The Clinical Guidelines for Stroke Management (2017)5 recommend that “rehabilitation should be structured to provide as much scheduled therapy (occupational therapy and physiotherapy) as possible”. A study by Ryan and colleagues15 investigated whether more intensive home-based rehabilitation resulted in improved outcomes for patients following stroke. They found a small, but significant difference between groups in favour of the group that received the more intensive community rehabilitation. The WCORA team could consider delegating additional treatment sessions to the team’s rehabilitation assistants as a means of increasing stroke rehabilitation intensity. In this audit less than 20% of patients were seen by a rehabilitation assistant. Research has found a number of benefits from having assistants in the team, including increased intensity of clinical care.16,17

A positive finding from this audit is that where clinically indicated, patients continued to receive rehabilitation beyond three months. The WCORA team provides a goal-focused rehabilitation service and tailors the service provided to the individual’s needs rather than working to a defined time-period consistent with best practice guidelines.5,12 However, this prolonged input may impact on the ability of the team to pick up new patients in a timely fashion.

Despite the audit showing that best practice guidelines for delivery of community stroke rehabilitation were not met by the WCORA team, the service satisfaction questionnaire demonstrated generally positive feedback from patients. Care needs to be taken when interpreting the questionnaire results, however, as the overall sample size of this project was small, leading to a small number of returned surveys. It would be useful to administer another service satisfaction questionnaire to a larger sample of patients in order to confirm the results obtained in this audit. It may also be valuable to include an option for completing the survey online in addition to mailing out the survey, as mixed mode surveys produce a higher response rate than single mode surveys.18,19

We identified a number of limitations with the audit and the service satisfaction survey. Firstly, the findings are limited to one community team in Wellington, and may not be generalisable to the other community teams at CCDHB or in New Zealand. Secondly, while we measured the amount of rehabilitation undertaken with a health professional present, we did not make provisions for patients to record the amount of time they spent on rehabilitation outside of therapy appointments. Any future work investigating rehabilitation intensity following hospital discharge should consider applying for ethics approval to allow for the recruitment of patients to record time spent undertaking rehabilitation activities independently of their therapists. Thirdly, we had only a small sample size, therefore only a small number of patients returned the paper-based service satisfaction survey, meaning that the results need to be interpreted with caution. The use of an online survey in addition to mailing out surveys would be useful to consider for future audits. Fourthly, this audit did not specifically ask staff to document reasons for delays in service provision, however some staff did provide information on the data collection tool, and two broad categories were identified as potential reasons for delays. Future audits should include specific information on factors impacting commencement of rehabilitation. Finally, this audit did not document severity of stroke or disability, therefore it is impossible to determine whether the low number of contacts in the first four weeks following hospital discharge was clinically appropriate (at least for some patients), or whether further rehabilitation was indicated but was unable to be provided.

Conclusion

This prospective service audit revealed that the WCORA team is not currently meeting best practice recommendations for the provision of community stroke rehabilitation. There were delays in providing an initial appointment and the intensity of rehabilitation is lower than recommended. Suggestions for improving service responsiveness and intensity of rehabilitation have been made, as well as recommendations for future audits. Service redesign may be needed to improve community stroke rehabilitation provision against the MOH indicators, and further work is required at a team level to implement suggested changes.

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