High-Intensity Home-Based Rehabilitation for Stroke

Podcast Transcript

Introduction: Neuro Pathways, a Cleveland Clinic podcast exploring the latest research discoveries and clinical advances in the fields of neurology, neurosurgery, neuro rehab, and psychiatry.

Glen Stevens, DO, PhD:

In 2021, a multidisciplinary team at Cleveland Clinic implemented an innovative approach to delivering at-home rehabilitation therapy for patients following a stroke known has Home Care Plus. This model of high intensity home-based rehabilitation, which involves physical, occupational, and speech therapy, nursing services and custodial services aims to increase therapy service intensity to achieve functional improvement at lower cost than facility-based care. In today's episode of Neuro Pathways, we're discussing what has been learned about the model's effectiveness so far and how it might evolve in the future. I'm your host, Glen Stevens, neurologist/neurooncologist in Cleveland Clinic's Neurological Institute. I'm very pleased to have Dr. Joshua Johnson join me for today's conversation. Dr. Johnson is Director of Outcome Research in Cleveland Clinic Neurological Institute's Department of Physical Medicine and Rehabilitation. Josh, welcome to Neuro Pathways.

Joshua Johnson, PT, DPT, PhD:

Thank you so much, Dr. Stevens.

Glen Stevens, DO, PhD:

So Josh, for our listeners out there, tell us a little bit about yourself, a bit about your background, where you came from, how you made your way to the clinic.

Joshua Johnson, PT, DPT, PhD:

As you said, I am a physical therapist and researcher, and I realized early on in my physical therapy training that I was really interested in value-based care and what role physical therapists and occupational therapists and speech therapists can play in advancing value-based care for patients across the continuum. And so that led me to get a PhD at the University of Utah where I had the opportunity to start collaborating with some folks here at the Cleveland Clinic. And fortunately, that turned into a position here for me.

Glen Stevens, DO, PhD:

Well, great. Well, welcome to the Cleveland Clinic. How long have you been here?

Joshua Johnson, PT, DPT, PhD:

Just past four years.

Glen Stevens, DO, PhD:

Okay, great. So many years ago, I actually used to teach some physiology courses down at Cleveland State University for the PT and OT students. So always enjoyed my interaction, and to this day, of course, continue to enjoy my interaction with all the therapists. So we really appreciate what you do.

Joshua Johnson, PT, DPT, PhD:

Oh, thank you.

Glen Stevens, DO, PhD:

So your involvement with Home Care Plus began after it was initially implemented, is my understanding. And you were brought on, as you mentioned, as a researcher to evaluate the model's effectiveness. But in order to set the stage for our audience, can you first tell us a bit about the catalyst for this model and how it has evolved?

Joshua Johnson, PT, DPT, PhD:

Yeah, absolutely. So this really is the brainchild of some pretty innovative operational leaders here at Cleveland Clinic, including Dr. Jessica Holman, who's the president of the Cleveland Clinic Medicare ACO, Dr. Bill Zafirau, who's the medical director for Cleveland Clinic Connected Care and their teams. So they got together and identified that we send a lot of patients to facilities from the hospital across all hospitals, across all diagnoses, and they wondered how appropriate that was for all of those patients. So that was really the catalyst, is identifying some opportunity to help these patients get home in their own environment, where most patients would prefer to be anyway, in a way that is cost-effective while still providing rehabilitation and other services that these patients might need in order to recover after their hospitalization.

Glen Stevens, DO, PhD:

My understanding is the team conducted a pilot study starting in 2019 for alternative post-acute care management, and then narrowed the scope mostly to stroke patients. Can you talk about that at all? I know that was a little bit before you started with it.

Joshua Johnson, PT, DPT, PhD:

Yeah. So I was excited. I was hearing about these rumors about this alternative post-acute care model that they were doing in four Cleveland Clinic regional hospitals, really for all comers. It was patients who met really basic eligibility criteria in terms of their functional deficits and their medical status. And in doing so, they didn't really have a lot of clarity around the types of patients that would be most appropriate. And so we're actually in the midst now of analyzing close to 100 patients who have gone through that pilot program. And again, it's all diagnoses. And so we're seeing a lot of variability, as you might imagine, in the types of patients we see and the types of care that they need. And we're trying to understand better how to make sense of that. And so I was fortunate to tap into this enterprise effort and ask if I could do some analyses, retrospective analyses, at least, to understand the impact of this care model for these patients. And then that turned into a really nice collaboration where we identified that for patients with stroke, we know that rehabilitation is an evidence-based practice after their stroke. And so we identified that this is a really nice opportunity to prospectively implement this Home Care Plus model for that specific patient population. And that's really where my work is focused now.

Glen Stevens, DO, PhD:

So I imagine starting in 2019 and then the pandemic rolling right into this, must have been really challenging for care of these patients.

Joshua Johnson, PT, DPT, PhD:

In a lot of ways, and also insightful in a lot of ways because especially during the pandemic, patients were much more resistant than usual to go to facilities. So they were asking to find ways to go home, which is good and bad. Again, this model is meant for patients who need rehabilitation, and here, we suddenly had an uptick of patients who wanted to go home but needed additional services that would be typically provided in traditional home care. And so I think that's part of what contributed to the fact that we saw a lack of fidelity in maintaining the clinical criteria that these patients needed just because we were trying to create a way for these patients in the middle of the pandemic to receive care. And Home Care Plus was at least one way to do that, even though it wasn't necessarily the model that it needed to be for this specific patient group. So Dr. Holman, who I mentioned, is now doing some additional work to try to understand for patients who would like to go home and maybe could be managed appropriately at home but don't necessarily need a lot of rehabilitation, what's the appropriate care model for them if it's not at a skilled nursing facility?

Glen Stevens, DO, PhD:

So it sounds like it was definitely stress tested.

Joshua Johnson, PT, DPT, PhD:

It has been, and it's continuing to be stress tested. Absolutely.

Glen Stevens, DO, PhD:

So tell us a bit about your role in regards to this model and what you are looking to achieve. I understand that you received a five-year agency for healthcare research and quality KL1 grant to evaluate this. So congratulations in that regard, but tell us your role.

Joshua Johnson, PT, DPT, PhD:

Yeah, so because I came in after the fact with the initial pilot but had some ideas about ways the rehabilitation could be shaped for patients with stroke specifically, I was able to interact with the team and provide some external evidence. For example, in Europe and in other countries across the world, they've developed what they call an early supported discharge model for patients with stroke, which is essentially what we're targeting. The difference is that in a lot of those countries, an in-patient rehabilitation facility is not an option. It's just not something that those countries have. And so most patients receive a lot of rehabilitation in the acute care hospital until they're ready to go home. So in that early supported discharge model, they're trying to create a way for these patients to leave the acute care hospital and go directly home with services in place that they might need.

And so I provided some evidence from some of that work to this team to help guide the way that we shaped this care model at Cleveland Clinic. And at this point, the way that the study is designed is we are now retrospectively examining the first cohort of patients who have gone through in the past year, which is about 40 patients. And we want to test whether the pilot test, again, this is a relatively small sample size, whether there is any measurable effect in terms of the patient's functional status and their readmission risk compared to patients who do go to in-patient rehabilitation facilities or skilled nursing facilities. We're also qualitatively assessing how clinicians feel about the implementation of this program, what has gone well, what has not gone well. And also interviewing patients and their at-home caregivers to ask them about their experience. And what we hope to do in subsequent aims of this five-year project that you mentioned is then feed that back to these same operational leaders who have designed the care model in hopes that we can redesign and re-implement based on feedback that we've received now from a quantitative analysis from our Cleveland Clinic caregivers and from patients and their at-home caregivers, and identify where there are weaknesses in our current model that we can strengthen and make this better in subsequent years.

Glen Stevens, DO, PhD:

So in general, do patients want to go home to do rehab, or do they want to go to a facility?

Joshua Johnson, PT, DPT, PhD:

Most patients would prefer to go home.

Glen Stevens, DO, PhD:

Okay. And what about caregivers? Same or would caregivers rather they go to a facility?

Joshua Johnson, PT, DPT, PhD:

There are a lot of caregivers who would prefer that they go to a facility. And one of the things that the clinicians who have been participating on the ground in this model noted is that a lot of time, a stroke is not an expected event. And so suddenly, the patient and their at-home caregivers have to decide, "What do we do now?" And at the very least, discharge from the hospital to an in-patient rehabilitation facility gives these families a week or two extra to figure out their plan for this patient at home. And so a lot of caregivers are interested in capitalizing on that opportunity. What's not clear, though, is if it is optimal for the patient's functional outcomes. Does that one to two week stay in a patient rehabilitation facility actually lead to better functional outcomes for these patients in the short and long term? And there's mixed evidence on that, and that's why we're interested in exploring an alternative model. But we do need to figure out how do we address the needs of patients and their at-home caregivers in order to make this model work.

Glen Stevens, DO, PhD:

Well, it sounds like the great news is you're going to get some really solid evidence down the road to help answer some of these questions, which is great.

Joshua Johnson, PT, DPT, PhD:

Yeah, we hope so.

Glen Stevens, DO, PhD:

Any initial results that you're seeing regarding the effectiveness of this model, or is it too early? Or anything you can share with us?

Joshua Johnson, PT, DPT, PhD:

Yeah, absolutely. We've just done mostly descriptive analyses at this point. But in general, patients are doing well. So these patients are discharged from the hospital at a functional level that would be consistent with maybe having difficulty walking down a hallway, for example. But by the time they're done with this program, which on average has lasted about 19 days for the entire home care episode, these patients are at a point where they can not only walk down a hallway but start to navigate an outdoor environment a little bit better. So what we're anxious to do is then compare and contrast those outcomes relative to patients who go to an in=patient rehabilitation facility and understand are the outcomes at least as good within about the same timeframe for these patients going home? Because again, we're aiming for giving patients an opportunity to heal in their own environment if that's what they're interested in. And if this means that their outcomes are the same at home than it would be for an in-patient rehabilitation facility, say, then that's higher value care. And that's really what we're after.

Glen Stevens, DO, PhD:

So you mentioned it a little bit some of the challenges with the caregiver and the difficulties there. Is there any other challenges for the patient or the caregiver that you've noted?

Joshua Johnson, PT, DPT, PhD:

So a lot of the other challenges actually are not so much about the patient or the caregiver, but around our implementation and challenges that our own care teams have faced. And this was expected. This is a complex intervention for our health system to implement. It requires coordination of multiple disciplines across settings. And so there's communication that needs to be improved as clinicians in the hospital coordinate this care and as they try to communicate with the patient and their family about their options for post-acute care. The timing of that communication, who initiates that communication, all of those types of things have been challenging. And then for our home care clinicians, this is different. Home care therapy is typically one to two visits per week, per therapy service. And suddenly, we're asking these home care clinicians who already are very busy to provide four to five days a week of therapy for these patients in order to meet their needs. And that's challenging for them. And so it's been really challenging for our Center for Connected Care to match a staffing model that enables that high level of intensity of care. And so far, they've done a good job, but we'll see as we continue to increase volumes if they'll be able to keep pace.

Glen Stevens, DO, PhD:

Well, I suspect if you have PT, OT, speech, custodial, nursing coming in just coordinating who comes in when during the day got to be complicated.

Joshua Johnson, PT, DPT, PhD:

Yeah, and that's actually a great point, too, to your initial question about challenges for patients. That is one thing that the home care clinicians have noted that a lot of the patients, once they get home, we are not clear they didn't understand what they were signing up for when they left the hospital or if they just changed their minds. But a lot of them are saying, "I don't want all of you coming to my house. This is too much." And so they kind of pick and choose which services they need most, which is probably okay as long as we're helping them to achieve the outcomes that matter to them. That's another thing we're working on, is trying to figure out how do we actually match the services we provide to what patients need and what they want, and if there's more that we can provide that we think can help with their outcomes, how do we communicate that effectively to them?

Glen Stevens, DO, PhD:

Yeah, that sounds really to be the key term today, communication.

Joshua Johnson, PT, DPT, PhD:

Absolutely.

Glen Stevens, DO, PhD:

So that on both sides, there's a good understanding. But this is why we do pilot studies and these things so that we'll gather that information so that we'll all be smarter. I'm just curious, if I go to a rehab somewhere, the number of hours that I'm doing at the rehab center versus the at-home model, is it similar total number of hours? Is one different from the other?

Joshua Johnson, PT, DPT, PhD:

In-patient rehabilitation facilities, Medicare actually requires that every patient receives 15 hours of therapy per week between PT, OT and speech. When patients go home with regular home care, they get maybe three to four hours across all three disciplines per week. So that's really what we're after when we say high intensity home-based rehabilitation via this Home Care Plus model, is we're we're just trying to increase that service intensity so that instead of three or four hours, you're getting at least double that so that it's a little more consistent with what you would get if you were at in-patient rehabilitation.

Glen Stevens, DO, PhD:

Talk to us about next steps, other things you're thinking about working on, long-term goals.

Joshua Johnson, PT, DPT, PhD:

So I'm really anxious to conduct these analyses that are part of the first couple of aims of this five-year project, which again, will allow us to quantitatively examine the clinical effectiveness of this care model, but also qualitatively understand what's gone well and hasn't. The most immediate next step that I think I'm looking forward to the most is then going back to our clinical leaders and sharing the results of our analyses with them. Because what's going to be really fun is then identifying ways that we can do better. Our patients need us to continue to improve, and this is a really great way for us to do that. Assuming that all goes well, this is, again, a novel model for post-acute rehabilitation, and so we do have plans to try to scale it. Right now, we're only doing it at one Cleveland Clinic hospital. So what scaling looks like is still up in the air, whether that's other Cleveland Clinic hospitals or partnering with other hospital systems who would be interested in trialing this model of care and are capable of doing so. But that's kind of the longer term vision. In the short term, we're just anxious to understand how well it's going and figure out how to make it better.

Glen Stevens, DO, PhD:

So do we have enough PTs, OTs, speech therapists to do this?

Joshua Johnson, PT, DPT, PhD:

There's been some evidence recently that with payment reform instigated by CMS, there are now fewer therapists getting jobs in skilled nursing facilities, for example. So as long as we continue to produce enough therapists, there will be fewer jobs in skilled nursing facilities, but perhaps more jobs in home care to support this type of model.

Glen Stevens, DO, PhD:

And is there a role for virtual visits with this, or does it have to be everybody have to be in person?

Joshua Johnson, PT, DPT, PhD:

Yeah, so that's something we've scratched the surface on in our conversations, especially Steve Paymer is a director of therapy services for Cleveland Clinic Home Care, and that's something he's brought up. A vision of his is ways that we can compliment care using virtual services, whether that's something as simple as a phone call or some sort of telehealth visit. But there's definitely some opportunity to explore that down the road.

Glen Stevens, DO, PhD:

So Home Care Plus 2.0, take home points for our listeners.

Joshua Johnson, PT, DPT, PhD:

Yeah, so I think when we do this again, optimizing communication within disciplines, within the hospital and from the hospital into home care. I don't know exactly how that communication will be optimized. We're hoping to continue to gain feedback from our partners and understand that better, but that will be a key goal. I think making it more patient-centered so that individual patients will have services matched to their specific needs as opposed to kind of a blanket. This is what the Home Care Plus program is, it's five visits of PT and four visits of OT. We won't do that as much. We'll understand a little bit better. For this patient, you need a lot of speech therapy and less occupational therapy. And then I do think it might be Home Care Plus 2.2, but looking at some sort of model that includes virtual care, as well.

Glen Stevens, DO, PhD:

So if somebody's out there thinking, "This sounds good. We'd like to do this at our institution, as well," words of wisdom for someone that wants to implement a program like this.

Joshua Johnson, PT, DPT, PhD:

I might give one piece of advice. There's certainly much more I could say, but probably the most important thing I could say is gather a multidisciplinary team of partners who is anxious to do something better for patients. Because if you get the right people in the room who have a shared goal in doing something like this, then I think everything else will start to fall into place.

Glen Stevens, DO, PhD:

I really applaud what you're doing. I'll congratulate you again on the K award. Very exciting and certainly something that will help springboard your research career as it moves forward. And as I'm getting older, I applaud the efforts that you do. Hopefully I'll never need them, but I need people to look after people with neurologic problems and look forward to only great things ahead from you.

Joshua Johnson, PT, DPT, PhD:

Thank you so much, Dr. Stevens.

Conclusion: This concludes this episode of Neuro Pathways. You can find additional podcast episodes on our website, clevelandclinic.org/neuropodcast, or subscribe to the podcast on iTunes, Google Play, Spotify, or wherever you get your podcasts. And don't forget, you can access real-time updates from experts in Cleveland Clinic's Neurological Institute on our Consult QD website. That's consultqd.clevelandclinic.org/neuro, or follow us on Twitter @CleClinicMD, all one word. And thank you for listening.