In the United States, approximately 70% of Medicare beneficiaries are discharged for acute stroke with Medicare-covered postacute stroke care. After hospitalization, the largest proportion of patients are first referred to a skilled nursing facility (SNF; 32%), 22% to an inpatient rehabilitation facility (IRF), and 15% to a home healthcare agency (HHCA). The authors point out that policy makers and researchers should strive for a better understanding of patient outcomes in different rehabilitation settings, specifically relative to use and cost.

In their review of the medical literature, the panelists found that there were substantial baseline differences in patients between rehabilitation settings. For example, IRF patients had a more favorable prognostic outlook because of their younger age, lower prestroke disability, fewer comorbidites, and greater caregiver or family support.

In their recommendations for levels of care in organization of post-stroke rehabilitation care, the panel recommended the following: patients who are candidates for postacute rehabilitation should receive organized, coordinated, interprofessional care (class I, level of evidence A); stroke survivors who qualify for and have access to IRF care should receive treatment in that setting vs an SNF (class I, level of evidence B); organized community-based and coordinated interprofessional rehabilitation care should occur in outpatient or home-based settings (class I, level of evidence C); and finally, ESD services may be reasonable for patients with mild to moderate disability (class IIb, level of evidence B).

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In their recommendations for rehabilitation interventions in the inpatient hospital setting, the panel recommended that early rehabilitation for hospitalized patients be provided in environments with organized, interprofessional stroke care (class I, level of evidence A), and stroke survivors should receive rehabilitation at an intensity commensurate with anticipated benefit and tolerance (class I, level of evidence B). They also found that high-dose, very early mobilization within 24 hours of stroke onset can reduce odds of favorable outcomes at 3 months, and therefore is not recommended (class III, level of evidence A).

According to the authors, postacute stroke care and rehabilitation are often considered expensive healthcare costs, and as systems of care evolve, adequate resources should remain a priority to prevent further “downstream medical morbidity.”

“Stroke rehabilitation requires a sustained and coordinated effort from a large team,” the panel concluded. “Communication and coordination among these team members [eg, physicians, nurses, physical and occupational therapists, family, and other caregivers] are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline.”

“Without communication and coordination,” they stressed, “isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential.”


Winstein CJ, Stein J, Arena R, et al; on behalf of the American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Quality of Care and Outcomes Research. Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2016. doi:10.1161/STR.0000000000000098.

This article originally appeared on The Cardiology Advisor