Daily Hand-Off of Chronic Stroke Neurorehabilitation Patients to Expert Clinicians, With Resulting Significant Coordination Improvement: Care Model Development and Implementation

Main Article Content

Jessica P McCabe Janis J Daly Michelle Monkiewicz Marianne Montana Kristi Butler Jean Rogers David Aron

Abstract

Background:  New models of care delivery are necessary to meet workforce needs while delivering expert care in neurorehabilitation. Therefore, we sought to develop and assess the implementation of a new model of care for neurorehabilitation using a 5-member team of therapists (5-Team Model) for the treatment of individuals with chronic stroke, rather than a conventional single-therapist model. 


Methods:  A mixed methods approach was employed; continuous quality improvement methods and quasi-experimental pre-test/post-test methods were used to assess the effectiveness of the new model.


Six chronic stroke patients participated in an upper limb neurorehabilitation motor learning protocol 5 days/week, 5 hours/day (60 sessions; 300 hours); treatment was administered using the 5-Team Model approach to treatment.


Results:  Mean improvement on the Fugl Meyer (FM) was 11.5 points.  All six participants demonstrated improvement on Fugl Meyer that was within or beyond the minimal clinically important difference (MCID) range of 4.25-7.25 points for chronic stroke.  Results indicated that the 5-Team Model was effective in implementing care.


Conclusions:  The 5-Team Model for neurorehabilitation was successfully implemented, with patient hand-off every day to a different therapist; it produced clinically significant improvement on a measure of coordination (FM) which is comparable to or better than prior reports from a standard care model.  This new model of care met the needs of the research team workforce for flexibility, while maintaining the level of quality of care.  Successful implementation required addressing a series of hindering factors in an iterative manner and enhancing promoting factors.  These elements included the context within which the change was implemented, the methods used in implementing the change, the evidence that the change was successful, and communication that the change was successful.  The context requirements included existing framework and participating model members who were willing to exert the required effort for success, model champions.  This high level of enthusiastic participation along with strong leadership contributed to long-term success, sustainability.


 

Article Details

How to Cite
MCCABE, Jessica P et al. Daily Hand-Off of Chronic Stroke Neurorehabilitation Patients to Expert Clinicians, With Resulting Significant Coordination Improvement: Care Model Development and Implementation. Medical Research Archives, [S.l.], v. 9, n. 4, apr. 2021. ISSN 2375-1924. Available at: <https://esmed.org/MRA/mra/article/view/2342>. Date accessed: 14 may 2021. doi: https://doi.org/10.18103/mra.v9i4.2342.
Section
Research Articles

References

1. Cameron ID. Models of rehabilitation – commonalities of interventions that work and of those that do not. Disabil Rehabil. 2010;32(12):1051-1058. doi:10.3109/09638281003672377
2. Teasell R, Meyer MJ, Foley N, Salter K, Willems D. Stroke Rehabilitation in Canada: A Work in Progress. Top Stroke Rehabil. 2009;16(1):11-19. doi:10.1310/tsr1601-11
3. Gropen T, Magdon-Ismail Z, Day D, Melluzzo S, Schwamm LH. Regional Implementation of the Stroke Systems of Care Model: Recommendations of the Northeast Cerebrovascular Consortium. Stroke. 2009;40(5):1793-1802. doi:10.1161/STROKEAHA.108.531053
4. Abilleira S, Gallofré M, Ribera A, Sánchez E, Tresserras R. Quality of in-hospital stroke care according to evidence-based performance measures: results from the first audit of stroke, Catalonia, Spain. Stroke. 2009;40(4):1433-1438. doi:10.1161/STROKEAHA.108.530014
5. Robinson J. Facilitating earlier transfer of care from acute stroke services into the community. Nurs Times. 2009;105(12):12-13.
6. Gregory PC, Han E. Disparities in Postacute Stroke Rehabilitation Disposition to Acute Inpatient Rehabilitation vs. Home: Findings from the North Carolina Hospital Discharge Database. Am J Phys Med Rehabil. 2009;88(2):100-107. doi:10.1097/PHM.0b013e3181951762
7. Reding MJ, McDowell FH. Focused Stroke Rehabilitation Programs Improve Outcome. Arch Neurol. 1989;46(6):700-701. doi:10.1001/archneur.1989.00520420122034
8. Alonso de Leciñana-Cases M, Gil-Núñez A, Díez-Tejedor E. Relevance of Stroke Code, Stroke Unit and Stroke Networks in Organization of Acute Stroke Care – The Madrid Acute Stroke Care Program. Cerebrovasc Dis. 2009;27(1):140-147. doi:10.1159/000200452
9. Clarke DJ. Achieving teamwork in stroke units: The contribution of opportunistic dialogue. J Interprof Care. 2010;24(3):285-297. doi:10.3109/13561820903163645
10. Rapoport J, Judd-Van Eerd M. Impact of Physical Therapy Weekend Coverage on Length of Stay in an Acute Care Community Hospital. Phys Ther. 1989;69(1):32-37. doi:10.1093/ptj/69.1.32
11. Duncan C, Hudson M, Heck C. The impact of increased weekend physiotherapy service provision in critical care: a mixed methods study. Physiother Theory Pract. 2015;31(8):547-555. doi:10.3109/09593985.2015.1060657
12. Scotten M, Manos EL, Malicoat A, Paolo AM. Minding the gap: Interprofessional communication during inpatient and post discharge chasm care. Patient Educ Couns. 2015;98(7):895-900. doi:10.1016/j.pec.2015.03.009
13. Arora V, Johnson J. A Model for Building a Standardized Hand-off Protocol. Jt Comm J Qual Patient Saf. 2006;32(11):646-655. doi:10.1016/S1553-7250(06)32084-3
14. O’Brien CM, Flanagan ME, Bergman AA, Ebright PR, Frankel RM. “Anybody on this list that you’re more worried about?” Qualitative analysis exploring the functions of questions during end of shift handoffs. BMJ Qual Saf. 2016;25(2):76-83. doi:10.1136/bmjqs-2014-003853
15. Zakrison TL, Rosenbloom B, McFarlan A, et al. Lost information during the handover of critically injured trauma patients: a mixed-methods study. BMJ Qual Saf. 2016;25(12):929-936. doi:10.1136/bmjqs-2014-003903
16. Batalden PB, Nelson EC, Edwards WH, Godfrey MM, Mohr JJ. Microsystems in Health Care: Part 9. Developing Small Clinical Units to Attain Peak Performance. Jt Comm J Qual Saf. 2003;29(11):575-585. doi:10.1016/S1549-3741(03)29068-7
17. Daly JJ, Hogan N, Perepezko EM, et al. Response to upper-limb robotics and functional neuromuscular stimulation following stroke. JRehabilResDev. 2005;42(1938-1352 (Electronic)):723-736.
18. McCabe J, Monkiewicz M, Holcomb J, Pundik S, Daly JJ. Comparison of Robotics, Functional Electrical Stimulation, and Motor Learning Methods for Treatment of Persistent Upper Extremity Dysfunction After Stroke: A Randomized Controlled Trial. Arch Phys Med Rehabil. 2015;96(6):981-990. doi:10.1016/j.apmr.2014.10.022
19. Daly JJ, McCabe JP, Holcomb J, Monkiewicz M, Gansen J, Pundik S. Long-Dose Intensive Therapy Is Necessary for Strong, Clinically Significant, Upper Limb Functional Gains and Retained Gains in Severe/Moderate Chronic Stroke. Neurorehabil Neural Repair. 2019;33(7):523-537. doi:10.1177/1545968319846120
20. Chevalier JM, Buckles DJ. Participatory Action Research: Theory and Methods for Engaged Inquiry. 2nd ed. Routledge; 2019. doi:10.4324/9781351033268
21. Fugl-Meyer AR, Jääskö L, Leyman I, Olsson S, Steglind S. The post-stroke hemiplegic patient. 1. a method for evaluation of physical performance. Scand J Rehabil Med. 1975;7(1):13-31.
22. Santisteban L, Térémetz M, Bleton J-P, Baron J-C, Maier MA, Lindberg PG. Upper Limb Outcome Measures Used in Stroke Rehabilitation Studies: A Systematic Literature Review. Tremblay F, ed. PLOS ONE. 2016;11(5):e0154792. doi:10.1371/journal.pone.0154792
23. Page SJ, Fulk GD, Boyne P. Clinically importance differences for the upper-extremity Fugl-Meyer Scale in people with minimal to moderate impairment due to chronic stroke. Phys Ther. 2012;92:791-798 doi:10.1177/0269215512464795
24. Grol RPTM, Bosch MC, Hulscher MEJL, Eccles MP, Wensing M. Planning and Studying Improvement in Patient Care: The Use of Theoretical Perspectives: Planning and Studying Improvement in Patient Care. Milbank Q. 2007;85(1):93-138. doi:10.1111/j.1468-0009.2007.00478.x
25. Ward NS, Brander F, Kelly K. Intensive upper limb neurorehabilitation in chronic stroke: outcomes from the Queen Square programme. J Neurol Neurosurg Psychiatry. 2019;90(5):498-506. doi:10.1136/jnnp-2018-319954
26. Page SJ, Levine PG, Basobas BA. “Reps” Aren’t Enough: Augmenting Functional Electrical Stimulation With Behavioral Supports Significantly Reduces Impairment in Moderately Impaired Stroke. Arch Phys Med Rehabil. 2016;97(5):747-752. doi:10.1016/j.apmr.2016.01.004
27. Lum PS, Burgar CG, Shor PC, Majmundar M, Van der Loos M. Robot-assisted movement training compared with conventional therapy techniques for the rehabilitation of upper-limb motor function after stroke. Arch Phys Med Rehabil. 2002;83(7):952-959. doi:10.1053/apmr.2001.33101
28. Nudo RJ, Wise BM, SiFuentes F, Milliken GW. Neural Substrates for the Effects of Rehabilitative Training on Motor Recovery After Ischemic Infarct. Science. 1996;272(5269):1791-1794. doi:10.1126/science.272.5269.1791
29. Nudo R, Milliken G, Jenkins W, Merzenich M. Use-dependent alterations of movement representations in primary motor cortex of adult squirrel monkeys. J Neurosci. 1996;16(2):785-807. doi:10.1523/JNEUROSCI.16-02-00785.1996
30. Pascual-Leone A, Torres F. Plasticity of the sensorimotor cortex representation of the reading finger in Braille readers. Brain. 1993;116(1):39-52. doi:10.1093/brain/116.1.39
31. Bütefisch C, Hummelsheim H, Denzler P, Mauritz K-H. Repetitive training of isolated movements improves the outcome of motor rehabilitation of the centrally paretic hand. J Neurol Sci. 1995;130(1):59-68. doi:10.1016/0022-510X(95)00003-K
32. Elbert T, Pantev C, Wienbruch C, Rockstroh B, Taub E. Increased Cortical Representation of the Fingers of the Left Hand in String Players. Science. 1995;270(5234):305-307. doi:10.1126/science.270.5234.305
33. Dean CM, Shepherd RB. Task-Related Training Improves Performance of Seated Reaching Tasks After Stroke: A Randomized Controlled Trial. Stroke. 1997;28(4):722-728. doi:10.1161/01.STR.28.4.722
34. Singer RN, Lidor R, Cauraugh JH. To Be Aware or Not Aware? What to Think about while Learning and Performing a Motor Skill. Sport Psychol. 1993;7(1):19-30. doi:10.1123/tsp.7.1.19
35. Plautz EJ, Milliken GW, Nudo RJ. Effects of repetitive motor training on movement representations in adult squirrel monkeys: role of use versus learning. Neurobiol Learn Mem. 2000;74(1):27-55. doi:10.1006/nlme.1999.3934
36. Resnik L, Jensen GM. Using clinical outcomes to explore the theory of expert practice in physical therapy. Phys Ther. 2003;83(12):1090-1106.
37. Winstein CJ. Knowledge of Results and Motor Learning—Implications for Physical Therapy. Phys Ther. 1991;71(2):140-149. doi:10.1093/ptj/71.2.140
38. Riolo L. Skill Differences in Novice and Expert Clinicians in Neurologic Physical Therapy: Neurol Rep. 1996;20(1):60-63. doi:10.1097/01253086-199620010-00021
39. Bloom BS, Englehart MB, Furst EJ, Hill WH, Krathwohl DR. Taxonomy of Educational Objectives: The Classification of Educational Goals. Handbook 1: Cognitive Domain. Longman; 1956.
40. Shivakumar K, Pujar V. Work Life Balance in the Health Care Sector. Published online 2018. doi:10.13140/RG.2.2.19413.73440

Most read articles by the same author(s)

Obs.: This plugin requires at least one statistics/report plugin to be enabled. If your statistics plugins provide more than one metric then please also select a main metric on the admin's site settings page and/or on the journal manager's settings pages.