Introduction: Post-acute care (PAC) may be an important factor in recovery, yet little is known about stroke patients’ receipt of PAC across settings. To optimize future PAC, we described all settings in which stroke survivors receive therapy, the total time receiving therapy in each setting and transitions between settings.
Methods: All Medicare fee-for-service patients admitted in 2011 and discharged alive with a primary diagnosis of acute ischemic stroke or intracerebral hemorrhage (ICD-9-CM 431, 433.x1, 434.x1, 436) were identified from the Medicare Inpatient file. Medicare Standard Analytic Files were used to identify therapy in all PAC settings — hospital, Inpatient Rehabilitation Facilities (IRF), Skilled Nursing Facilities (SNF), Home Health (HH) and Outpatient for 12 months after the index stroke admission. Physical (PT), occupational (OT) and speech therapy (SLP) were identified using CPT and revenue codes. For each therapy modality, minutes of therapy was estimated by cross-walking Medicare billing codes to the American Medical Association’s average intra-service time for each code. We then estimated time in each therapy modality, total therapy time in each PAC setting and the number of transitions between settings.
Results: Our cohort included 186,168 patients, 59% female with a mean age of 80.1 (SD 8.2). 86%, 78% and 74% received any PT, OT or SLP. For patients who received a specific therapy modality, the median therapy minutes was: 762 PT, 661 OT, and 684 SLP. Of all patients, 22% received PT in an IRF, 38% in a SNF, 23% in HH and 36%. For patients who received PT in a given setting, the median number of minutes per setting was: 86 hospital, 747 IRF, 718, 446 HH, and 553 outpatient. Slightly smaller proportions received OT and SLP for slightly shorter times across settings.
Multiple care transitions were common. Of all patients, 75% had more than 1 transition, 45% have 3+, 25% have 5+, 14% have 7+ and 6% have 9+ in the 12 months following stroke.
Conclusions: During the first year following their stroke, the median stroke survivor who receive therapy spends 35 hours in therapy and has 3 transitions between settings. Most therapy is delivered outside of the hospital and settings transitions are common raising concerns for care fragmentation.