Early Supported Discharge and Continued Rehabilitation At Home After Stroke

Abstract

This review is based on studies conducted in the Stockholm County that sought to explore and compare the behavior of patients and therapists during stroke rehabilitation sessions in the home and in the hospital. The study also describes a program of early supported discharge and continued rehabilitation at home for patients with moderate neurological impairments after stroke; and evaluates the effect of the program, in terms of patient outcome, resource use and cost of health-care in comparison with routine rehabilitation. Eighty-three patients were included in a randomized controlled trial: 41 were allocated to rehabilitation at home (HRG) and 40 to routine rehabilitation (RRG). Follow-up of patient outcome was performed at 3, 6 and 12 months, patient satisfaction at 3 months, and resource use over 12 months. Observations and semi-structured interviews were used to explore the behavior of therapists and patients during rehabilitation sessions, and to describe the content and implementation of the intervention program. The intervention program varied in duration (4–29 weeks, mean = 14), frequency of home visits (3–31 visits, mean = 12) and content. The rehabilitation was planned and carried out in partnership between the patient and the therapist. Face-to-face contact with the patient was spent in dialogue and training. Self-directed training was performed an average of 1½ h a day per patient. The home of the patient was found to provide an environment more amenable than the hospital for a stroke rehabilitation session whose aim was promoting active patient participation. In the RRG, 20 patients were discharged to their homes and 18 were transferred to departments of geriatrics or rehabilitation, where they had 1142 rehabilitation contacts. Patient satisfaction with participation in planning the rehabilitation was significantly better in the HRG than in the RRG (p = 0.021) and at least as good in all other domains. At 1 year, 77 patients — 39 in the HRG and 38 in the RRG — were followed-up. There was no difference in patient outcome. By multiple regression analysis, intervention was suggested to have a significant effect on independence in activities of daily living. During the first year after stroke a significant difference in in-patient hospital care was observed, with means of 18 (HRG) versus 33 days (RRG)(p = 0.002); there was no difference in other resource use. In Sweden, early supported discharge with continued rehabilitation at home proved no less beneficial than routine rehabilitation. The average cost of health-care for five patients in the HRG during 1 year was similar to that for four patients in the RRG.