Home-based rehabilitation for people with stroke: a comparative study of six community services providing co-ordinated, multidisciplinary treatment

Abstract

Objective: To describe and compare six community services providing co-ordinated, multidisciplinary rehabilitation to people with stroke. Design: Prospective, descriptive, quantitative study. Setting: England and Northern Ireland. Subjects: Community rehabilitation teams and the patients treated by them. Main outcome measures: Annual numbers treated, Barthel Index, mortality, place of discharge, crude costs. Results: Between mid-1997 and mid-1999, data were collected on 1076 patients who received community-based rehabilitation of whom 48.7% were male. Mean age (SD) was 71 years (13.1); 115 (10.7%) were under 55 years of age and 278 (25.9%) under 65 years of age. Median time between stroke and intervention by the community service was six weeks (25th, 75th percentiles 2.6, 14.4 weeks) and 80.5% had been admitted to hospital. The median Barthel score at the start of community rehabilitation was 15 (11.0, 18.0) and at the end was 18.0 (14.0, 20.0). Median duration of intervention was 12 weeks (6.0, 22.0). At the end of community rehabilitation 912 patients (86.5%) were in the community, 52 (4.9%) had died, 10 (0.9%) were in hospital and 77 (7.3%) in long-term care. Comparative data given here are for one year, 1998, when a total of 519 patients began community rehabilitation. Details of 1855 face-to-face interventions were also recorded from subsets of 10 consecutive patients. Conclusions: Community rehabilitation teams differed in their target populations, in the timing and duration of intervention. A taxonomy of four types of co-ordinated community-based rehabilitation for people with stroke is proposed: (1) Early-supported discharge rehabilitation aimed to reduce length of hospital stay and offered an alternative to hospital rehabilitation. (2) Post-discharge rehabilitation provided additional rehabilitation and aimed for a seamless transfer of patients from hospital to community. (3) General practitioner-oriented post-stroke rehabilitation provided an alternative to hospital admission and rehabilitation. (4) Late community rehabilitation provided patients with the opportunity of an autonomous service, unconnected with hospital or GP referral. Purchasers need to decide for what purpose a team is to be set up. Researchers need to be similarly aware of diversity in community rehabilitation before comparisons are made.