>> Hello. I'm Dr. April Pruski,
and I'm an assistant professor in
the Chieminal Department at Johns Hopkins.
I'm also the medical director of
the Chieminal Consultation Service Line.
Today, Annette and I are going to be talking about
the Acute Hospital Rehabilitation Intensive Service model
of care in stroke.
>> Hi, I'm Annette Lavezza.
I'm an assistant professor of Chieminal and
the director of inpatient therapy services
of Johns Hopkins Hospital,
and I have the pleasure of joining April for our discussion today.
We'll start with, that we have no financial disclosures.
Then let's jump to a definition of what
the Acute hospital rehabilitation intensive service is.
We refer to that as A-RISE or ARISE.
It is a program that we created at Hopkins for
targeted patient population so that they
can receive higher intensity therapy
in the acute hospital setting.
Our traditional models of therapy have focused
on providing an evaluation and moving
patients to the next level of
care and have left little opportunity for
us to be able to provide
intervention while a patient is in the acute care setting.
We designed the program and initiated it with
several populations and we used
it with our liver transplant patients,
we used it during the initial waves of
COVID as well as with stroke.
We really focused on
coordinated early rehabilitation care
outside of the rehabilitation unit.
As early as in the ICU,
but also in [inaudible] so coordinated [inaudible] care,
we have medical management,
coordination and therapy teams,
medical teams and care management teams,
and then therapists interventions focusing both on
impairment remediation and compensation in
an effort to improve
patient's function before they're discharged,
rather than just focusing on moving them to
the place for those activities to start later.
In stroke, our goal is to evaluate and treat patients with
a wide range of deficits that are post-stroke related and
to identify for them appropriate
follow up to return to independent living.
All patients with new strokes who are admitted to
neurology at the Johns Hopkins Hospital
are included in the program.
They receive PT,
OT and SLP consultations for some reason and their impairments,
and they also all receive a PM&R consultation.
We're going to go into more detail about
what each of these groups offers.
There are two pillars of ARISE.
The first pillar is an enhanced therapy model and
the second pillar relates to rehabilitation huddles.
If we're going to break this down a little bit and talk about
each of them impacts 7,000 patients.
Our traditional model of acute care,
as I talked about before,
is that we are really looking at consultation for this nation.
We're focused on moving on to the next level.
There's really limited focus on intervention.
What we have a void with ARISE is this model of shorter,
more frequent therapy sessions.
Why did we choose shorter,
more frequent therapy sessions?
Well, we base that on data from the results,
from the overt trial 2016,
which suggests that shorter,
more frequent sessions per day could
improve the chance of regaining independence after stroke,
when they controlled for age and severity.
For example, 10 minute intervention 10
times a day suggested a more favorable outcome,
than longer, more intense,
less frequent therapy sessions.
Based on that information,
we have set up a structured model for how we
provide therapy for our arised patients and stroke.
Our enhanced therapy model includes PT, OT and SLP.
We provide daily interventions for our patients.
One of the very unique things about what we do for
our arised patients and
our stroke patients is that we are staff equal PT,
OT speech and that is not
the case for other areas in the Acute care hospital.
That gives us bench strength and the ability to provide
the enhanced therapy because we have
equal numbers of therapists for each discipline.
Ideally, we're seeing patients on weekdays
who are medically appropriate two
times a day for each discipline,
PT twice, OT twice each, each twice.
On weekends, they get daily therapy,
but it's alternating between disciplines.
Let's talk about what happens in those sessions because I think
this is an important focus of what we do.
We've asked the therapists to really think
about their obsessions and use one of
those sessions as a session that's more
focused on compensation and
another session that is more focused on remediation.
When we think about how we care for actual patients in the past,
a lion's share of what we've done is focused on compensation.
We have really talked about what do we need to get?
What do we need to put in place?
What adaptive equipment do we need?
What environmental changes do we need just
to get them moved to the next level of care?
Well, that's important.
We need to think about how do we
help patients do basic activities.
I'm unable to feed myself and you need to give
me a modification to help me be able to feel that's important.
The challenge is that it doesn't help me regain my skills.
It doesn't support the principles of
rehabilitation and doesn't necessarily restore my function.
It teaches me conventional strategies,
and that model of compensation is really
often consider or sometimes
consider what you would do if there isn't hope for recovery.
With our stroke patients,
we really hope [inaudible].
In that compensatory session we might be focused on.
How do I use an adaptive device so that I can use it.
Because that's important. I need to
be able to do that to have a home.
But then my second session of
the day really needs to look at remediation.
How do I take those principles of
neuro rehabilitation and that's practice and movement patterns and
work with that patient so that they can
develop more normalized movement patterns
so that they can feed themselves without
[inaudible] at some point in time.
We want to split out what happens in those two sessions.
The next pillar of,
the ARISE program is really a rehabilitation huddle.
We talked about how this was
a collaborative approach between therapy and physiatry.
Our goal is to really have
one unified rehab plan and improve the disposition guidance for
that patients so that they can continue in
their recovery as they move forward.
That one unified rehab plan is really key.
I think it is challenging for
our care management partners
if each of the disciplines is presenting
a different discharge disposition
and they are asked to do that out or there
isn't medical management components of
their recovery that would really help them progress.
The stroke huddle is scheduled daily Monday through Friday.
Everyone is present,
we've got a team who is working that day.
Physiatry and the therapists who are working that day.
Each of the disciplines provides an update.
So there's a current functional status report,
specification improving, are they plateauing,
are they defining how are they functioning?
What are the barriers to continue in progression?
Physiatry helps us with potential pharmacologic interventions,
specifically depression provisions basis
that as therapists we may not consider
as closely and so it's really
helpful to have that added layer of information.
Then need for any additional consultation.
We go through the list
for each patient each day and then that information from there we
apply back to the teams and care management teams and
we've been a cohesive rehabilitation approach
to what we're doing with patients.
>> Thank you Annette. Next we're going to be looking at
the Johns Hopkins affiliates to further describe what
this change the stroke rehabilitation model looked like.
The RISE stroke model of care at
Johns Hopkins began January of 2019.
We will be looking at a six month time from stroke discharges from
June 1st 2019 to December 31st of 2019.
Looking at the stroke care at the Johns Hopkins Hospital and
its affiliates we can see that the most discharges come
from JHH or Johns Hopkins Hospital and
BMC or Bayview Medical Center followed by
HCGH or Howard County Hospital then
SUB or Suburban Hospital and lastly at SIB or Sibley Hospital.
We have physiatry services at
both Bayview Medical Center and the Johns Hopkins Hospital.
The ARISE program is specifically at
Johns Hopkins Hospital where 92 percent of
stroke discharges received therapy visits.
Given that these two hospitals are both
comprehensive stroke centers with
similar number of stroke discharges,
we'll be comparing these two medical centers
in the next few slides.
Looking at the average length of stay we can see that
both Johns Hopkins Hospital and Bayview Medical Center each
have comparable median length of stay of
five days which is longer than
the other community affiliated hospitals of Howard County,
Sibley, and Suburban.
The average length of stay at Bayview is slightly lower at 7.9
days compared with Johns Hopkins Hospital which is 8.1 days.
Looking at the therapy total visits,
there is a significantly increased amount
of therapy given at Johns Hopkins Hospital of
5,382 visits compared to Bayview's 1,708 visits.
Patients at the Johns Hopkins Hospital service received
approximately three times more therapy visits
as compared with Bayview.
Looking at the bar graphs,
green is occupational therapy,
gray is physical therapy,
and blue is speech language pathology.
There is a more even amount of PT and
OT and SLP given in the total number of visits at
Johns Hopkins Hospital as in
that margin previously as compared with
Bayview which you can see provides
less speech language pathology services to patients.
Looking at the physiatry visits,
only 27 percent of
stroke patients were seen by a [inaudible] specialist at
Bayview Medical Center while at
Johns Hopkins Hospital 57 percent
of patients were seen by a Physiatrist.
Looking further into the physiatry visits,
patients at Johns Hopkins Hospital had
approximately four times more visits
than patients at the Bayview Medical Center.
Of the patients seen,
on average at Johns Hopkins Hospital patients were seen
three times while patients at Bayview were seen twice.
At Johns Hopkins one patient was seen 10 times during
their acute strokes day and at Bayview the
maximum physiatry follow up was four visits.
Now, looking at the discharge dispositions,
the orange and yellow represent discharge to post acute care.
The orange represents discharge to
sub-acute rehabilitation while the
yellow represents acute rehabilitation.
At Bayview 27.5 percent
of patients were discharged to sub-acute rehab
while only 14.1 percent of patients were
discharged to sub-acute rehab at the Johns Hopkins Hospital.
More patients were sent to
acute rehabilitation at Johns Hopkins than at Bayview.
The green represents home.
Over half the patients in
this time frame were discharged from Johns Hopkins Hospital to
home as compared to
39.3 percent of patients discharged from Bayview.
In conclusion
the acute hospital rehabilitation program is a model of
care that provides rehabilitation in
the acute hospital outside the traditional rehab unit.
The ARISE program has the potential to direct
rehabilitation services to the right patient at the right time.
While we can see that at
the John Hopkins Hospital stroke patients
received increased amounts
of therapy with comparable lengths of
stay compared to its affiliate of Bayview Medical Center,
we do not yet understand what
the long-term implications of the ARISE model are.
We will need further analysis to
understand if ARISE can impact length of stay,
total cost of care,
decreased long term disability,
and improve a patient's hospital experience.
Thank you for your attention to our presentation.