Heather Anne Hayes

Purpose: Examine clinical and non-clinical factors associated with post-acute rehabilitation placement after acute ischemic stroke. Methods: 236 adults hospitalized with acute ischemic stroke; independent and community-dwelling before stroke; and discharged to an inpatient rehabilitation facility (IRF; n = 171) or skilled nursing facility (SNF; n = 65). Clinical factors included NIHSS, Charlson Comorbidity Index (CCI), length of stay (LOS), AM-PAC “6-Clicks,” and neglect. Non-clinical factors included demographics and contextual characteristics. Logistic regression was used for associations with discharge location. Results: Individuals discharged to IRFs were younger, more likely to cohabitate, and had shorter LOS. Functional status (AM-PAC) and CCI did not differ significantly between groups despite differences in discharge destination. In univariable analyses, younger age, cohabitating marital status, living with family, available assistance, shorter LOS, private insurance, and higher NIHSS were associated with greater odds of IRF discharge. In the multivariable analysis, increasing age (OR 0.95, 95% CI 0.91–0.98) and greater comorbidity burden (CCI: OR 0.85, 95% CI 0.73–0.98) were associated with lower odds of IRF discharge. Marital status was not associated with discharge destination after adjustment. Conclusions: Among previously independent stroke survivors, discharged to an IRF or SNF increasing age and greater comorbidity burden were associated with lower odds of IRF placement after adjustment. NIHSS and AM-PAC Daily Activities scores were not associated with placement in the adjusted analysis.

Background: Discharge destination after acute ischemic stroke has implications for functional recovery and healthcare costs. Individuals discharged to inpatient rehabilitation facilities (IRFs) achieve better outcomes than those discharged to skilled nursing facilities (SNFs); however, many patients discharged to IRFs and SNFs have similar clinical profiles. We examined non-clinical factors associated with discharge location after acute ischemic stroke. Methods: Population: 236 adults hospitalized with acute ischemic stroke, living independently in the community prior to admission, and discharged to either an IRF (n=171) or SNF (n=65). Clinical variables: NIHSS, Charlson Comorbidity Index (CCI), acute care length of stay (LOS), functional status (AM-PAC “6-Clicks”), and neglect. Non-clinical variables: age, sex, race, marital status, insurance, home layout, living status, and available assistance. Associations with discharge location were evaluated using univariable and multivariable logistic regression and reported as odds ratios (OR) with 95% confidence intervals (CI). Results: Individuals discharged to IRFs were younger, more likely to cohabitate, and had shorter LOS than those discharged to SNFs. Functional status (AM-PAC) and comorbidity burden (CCI) did not differ significantly between groups despite differences in discharge destination. In univariable models, younger age, cohabitating marital status, living with family, available assistance, shorter LOS, private insurance, and higher NIHSS were associated with greater odds of IRF discharge. In multivariable analysis, younger age (OR 0.94, 95% CI 0.91–0.98), cohabitating marital status (OR 2.46, 95% CI 1.13–5.48), and shorter LOS (OR 0.88, 95% CI 0.82–0.93) remained independently associated with IRF discharge. Conclusions: Individuals with comparable pre-stroke independence and similar clinical severity, discharge to IRF versus SNF was independently associated with non-clinical factors; age, marital status, and LOS, whereas stroke severity and functional status were not significant predictors. These findings underscore the importance of evidence-informed discharge criteria integrating clinical indicators and social context to support equitable access to intensive rehabilitation after stroke.

Objective: This pilot study explored the feasibility and perceived usefulness of an educational intervention on intimacy delivered within a multidisciplinary ALS clinic. Methods: Individuals with ALS and their partners (if applicable) received the publicly available “Sexuality, Intimacy & Chronic Illness” fact sheet during routine clinic visits. A follow-up survey was conducted 4–6 weeks later to assess whether the information was informative, sufficient, and helpful. Demographic and clinical data were collected, and open-ended responses were analyzed descriptively. Results: Forty-two individuals received the fact sheet; 6 individuals and their partners (N = 12) completed follow-up surveys. Most respondents (83%) reported that ALS had impacted their intimate relationships, and 75% had discussed these changes with their partner. Half found the fact sheet informative, and 58% felt the information was sufficient. Open-ended responses revealed diverse needs, including interest in tailored content (eg, erectile dysfunction) and a desire for providers to ask permission before discussing intimacy. Caregivers described shifting roles and emotional strain, indicating that written materials alone may not fully address intimacy-related challenges. Conclusions: Integrating discussions of intimacy into ALS care is feasible and appreciated by some patients and partners. Although written educational materials may offer a useful starting point, a more personalized, consent-based approach—potentially modeled on frameworks like Ex-PLISSIT—may better address the relational needs of individuals with ALS and their caregivers. These findings support incorporating intimacy into holistic ALS care and developing guidelines to facilitate such discussions in multidisciplinary settings.

Background After discharged from the hospital for acute stroke, individuals typically receive rehabilitation in one of three settings: inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), or home with community services (i.e., home health or outpatient clinics). The initial setting of post-acute care (i.e., discharge location) is related to mortality and hospital readmission; however, the impact of this setting on the change in functional mobility at 90-days after discharge is still poorly understood. The purpose of this work was to examine the impact of discharge location on the change in functional mobility between hospital discharge and 90-days post-discharge. Methods In this retrospective cohort study, we used the electronic health record to identify individuals admitted to Johns Hopkins Medicine with an acute stroke and who had measurements of mobility [Activity Measure for Post Acute Care Basic Mobility (AM-PAC BM)] at discharge from the acute hospital and 90-days post-discharge. Individuals were grouped by discharge location (IRF=190 [40%], SNF=103 [22%], Home with community services=182 [(38%]). We compared the change in mobility from time of discharge to 90-days post-discharge in each group using a difference-in-differences analysis and controlling for demographics, clinical characteristics, and social determinants of health. Results We included 475 individuals (age 64.4 [14.8] years; female: 248 [52.2%]). After adjusting for covariates, individuals who were discharged to an IRF had a significantly greater improvement in AM-PAC BM from time of discharge to 90-days post-discharge compared to individuals discharged to a SNF or home with community services (β=-3.5 (1.4), p=0.01 and β=-8.2 (1.3), p=Conclusions These findings suggest that the initial post-acute rehabilitation setting impacts the magnitude of functional recovery at 90-days after discharge from the acute hospital. These findings support the need for high-intensity rehabilitation and for policies that facilitate the delivery of high-intensity rehabilitation after stroke.

Determine the level of agreement of three activity monitors compared with the gold standard (video review) on the activity level of patients with stroke. A prospective, observational, agreement study was performed on 47 individuals with sub-acute stroke in an inpatient rehabilitation facility. Data was collected during one physical therapy session. Individuals wore three device types; Actigraph (AG), Activpal (AP), and stepwatch activity monitor (SAM). Variables assessed were step counts for each limb (hemiparetic and non-hemiparetic) and percent time standing and other. Results from the activity monitors were compared to the video review and assessed for agreement using the intraclass correlation coefficient (ICC) and accuracy of mean difference from video observation. The step counts with the SAM on the non-hemiparetic limb had the highest ICC for step counts (ICC = 0.98, p < 0.001) and were overestimated with 21% accuracy. The SAM on the hemiparetic limb had 9.7% accuracy (ICC = 0.92, p < 0.001). For percent standing time all devices overestimated with poor reliability. For percent other activity time, the AP had the best accuracy and underestimated for both the hemiparetic limb (9.9% accuracy; ICC = 0.90, p < 0.001) and non-hemiparetic limb (8.3% accuracy; ICC = 0.84, p < 0.001). The use of multiple devices may be warranted to capture an accurate understanding of activity levels in this population of individuals with sub-acute stroke. There are concerns with all monitors and clinicians and researchers should be aware of what measures they are wanting to understand about their population.

Objective: The purpose of this study was to determine the factors influencing the discharge to an inpatient rehabilitation facility (IRF) or a skilled nursing facility (SNF) of people poststroke with Medicare Advantage plans. Methods: A retrospective cohort study was conducted with data from naviHealth, a company that manages postacute care discharge placement on behalf of Medicare Advantage organizations. The dependent variable was discharge destination (IRF or SNF). Variables included age, sex, prior living setting, functional status (Activity Measure for Post-Acute Care [AM-PAC]), acute hospital length of stay, comorbidities, and payers (health plans). Analysis estimated relative risk (RR) of discharge to SNF, while controlling for regional variation. Results: Individuals discharged to an SNF were older (RR = 1.17), women (RR = 1.05), lived at home alone or in assisted living (RR = 1.13 and 1.39, respectively), had comorbidities impacting their function “some” or “severely” (RR = 1.43 and 1.81, respectively), and had a length of stay greater than 5 days (RR = 1.16). Individuals with better AM-PAC Basic Mobility (RR = 0.95) went to an IRF, and individuals with better Daily Activity (RR = 1.01) scores went to an SNF. There was a substantial, significant variation in discharge of individuals to SNF by payer group (RR range = 1.12–1.92). Conclusions: The results of this study show that individuals poststroke are more likely to be discharged to an SNF than to an IRF. This study did not find a different discharge decision-making picture for those with Medicare Advantage plans than previously described for other insurance programs. Impact: Medicare Advantage payers have varied patterns in discharge placement to an IRF or SNF for patients poststroke.