Vicky SmithRehabilitation, Community & LTC Coordinator

October 2010

As indicated in the Final Report of the Stroke Rehabilitation System Consensus Panel 2007

2001 The Evidence-Based Review of Stroke Rehabilitation was begun

2003 The Canadian Stroke Network (CSN) launched its Stroke Canada Optimization of Rehabilitation through Evidence (SCORE) Project

2005 The MOHLTC funded the Consensus Panel on the Stroke Rehabilitation System

2006 SCORE/Canadian Stroke Quality of Care consensus meeting was convened on stroke rehabilitation outcome tools and system performance indicators

With the goal of establishing a core set of rehabilitation outcome measures to be used across the continuum.

2006 Canadian Best Practice Recommendations on Stroke Care were released

The Ontario Consensus Panel on the Stroke Rehabilitation System in 2007 state: Standard 5: stroke related impairments and functional status will be elevated by rehabilitation professionals trained in stroke rehabilitation using standardized, valid assessments.

The Canadian Best Practice Recommendations for Stroke Care 2008, state: 4iv & 5viii. Clinicians should use standardized, valid assessment tools to evaluate the patient’s stroke-related impairments and functional status.

The National Consensus panel used the following criteria for selection

◦ Published use in stroke trials (Evidence-Based)

◦ Strong psychometric properties (reliable and valid)

◦ Ease and feasibility of administration

◦ Potential for multidisciplinary administration (promote interprofessional collaboration and facilitate use when lacking access to all rehab professionals)

◦ Measurement can be used at admission and completion of rehabilitation

◦ The measurement can be administered in a multi-disciplinary fashion i.e. could be administered by anumber of different health professionals.(Important for smaller rehab centres that may not have all professionals)

◦ Time requirement should fit within the context of the usual assessment time of a health care professional.

All outcome measures selected by the panel were considered using the following criteria also.◦ Ease and feasibility of administration ◦ Content of the measure◦ Reliability ◦ Validity ◦ ResponsivenessTools were recommended to evaluate relevant

domains according to International Classification of Functioning (body structure and function, activity and participation)

Outcome measures: measures of change ( or lack of change) in the well-being of a defined population. Improvement in an outcome measure reflects the health status of the resident, whereas a process measure reflects the care delivery to the resident. Improvement in an outcome measure has adirect effect on mortality and morbidity.

Outcome measures are tools (instruments, questionnaires, scales, etc.) used to document change in client characteristics, functional abilities or behaviors, over time.

Interprofessional Collaboration: IPC is aclient-centered process of communication and decision making that enables the separate and shared knowledge and skills of healthcare providers to synergistically influence the care provider.

*Recommended by the Stroke Canada Optimization of Rehabilitation through Evidence/Canadian Stroke Quality of Care Study Stroke Rehabilitation Outcomes Panel

Request for a provincial review of the tools, and recommendation of a small set of 3 to 5 tools for provincial implementation

Provincial Outcome Measures Working group was formed with members from the OSS Rehabilitation Coordinators group

Purpose of this group was to make recommendation to the OSS Rehab and Community Engagement Subcommittee regarding provincial agreement on a core set (3 to 5) standardized outcome measures/tools from those outlined in the Canadian Stroke Strategy Best Practice recommendations.

Provide stroke survivors with consistency, enabling client self management through recovery process.

Promote use of a common language within teams and across transitions.

Facilitate measurement of stroke rehabilitation outcome measures across systems.

Ensure clinicians know which tools are valid, reliable measures that support best practices.

Improve ongoing data collection regarding stroke rehabilitation outcomes. This data collection will assist with:◦ Documenting the importance and benefits of

rehabilitation

◦ Facilitating the identification of gaps for the purposes of advocacy.

The domains and selected tools that meet the identified criteria are as follows:

Domain Tool 1. Balance Berg Balance Scale 2. Self Care Activities of Daily Living AlphaFIM® Instrument /FIM® Instrument 3.Cognition Montreal Cognitive Assessment ( MoCA) 4. Upper extremity/lower extremity structure and function (this was

classified as one domain as the one same tool is listed for both). Chedoke –McMaster Stroke Assessment (CMSA) Impairment Inventory 5. Language Boston Diagnostic Aphasia Examination (BDAE)

A survey was completed of the Central South Region on the current utilization of the recommended outcome measures.

Survey was circulated to all hospital acute care, inpatient and outpatient rehabilitation and community care agencies.

34 responses in total: ◦ Geographical range

◦ Professional range

Question 1: Are you currently using the recommended outcome measures in your setting/organization/agency with all stroke patients?

Of all the respondents:◦ Berg Balance Scale

◦ Chedoke-McMaster Stroke Assessment

◦ Montreal Cognitive Assessment

◦ Alpha FIM/FIM

◦ Boston Diagnostic Aphasia Exam

Question 2: Are staff members within your department/agency trained or certified on the recommended outcome measures?◦ Berg Balance Scale

◦ Alpha FIM/FIM

◦ Montreal Cognitive Assessment

◦ Chedoke-McMaster Stroke Assessment

◦ Boston Diagnostic Aphasia Examination

Question 3: If training/education/certification was provided, how many staff members would you want to attend?◦ Berg Balance scale

◦ Alpha FIM/FIM

◦ Montreal Cognitive

◦ Chedoke-McMaster

◦ Boston Diagnostic

Question 4: If you are not using the outcome measures, please indicate the tool and the reason why?

Most common responses:◦ “Tool not used with every stroke patient, due to

individual needs and therapists preference. Not indicated for the patient” 13 responses

◦ “Don’t like this tool” “Tool not sensitive to population” 9 responses

◦ “Not certified/not trained/not my discipline” 6 responses

The public has an expectation that health care practitioners communicate with each other within and across settings regarding their care.

Yet they consistently report duplication of assessments during their health care experience

It is important for Health care professionals to reach agreement on assessment tools, establish acommon language and share information about clients care across the continuum.

Most of the outcome measures are being used regionally and across the province. Are we utilizing the recommended outcome measures in the capacity they were intended?

There are limitations to the tools used in all areas of the continuum but particularly in the community and the hope is that more appropriate common assessment tools will be developed in the future.

There are challenges in finding tools that meet most or all criteria for selection therefore tool selection is based on best available. This seems to be especially true for language domain. The aphasia Institute is currently working on an outcome measure that is appropriate for stroke patients.

Are the outcome measures improving data collection regarding stroke rehabilitation outcomes?

Are we monitoring to make improvements?

Are there any training opportunities that we need to offer to our staff members?

Vicky Smith

Rehabilitation, Community & LTC Coordinator

October 2010