Objectives To (1) determine which clinical assessments at admission to an inpatient rehabilitation facility (IRF) most simply predict discharge walking ability, and (2) identify a clinical decision rule to differentiate household versus community ambulators at discharge from an IRF. Design Retrospective cohort study. Setting IRF. Participants Two samples of participants (n=110 and 159) admitted with stroke. Interventions A multiple regression determined which variables obtained at admission (age, time from stroke to assessment, Motricity Index, somatosensation, Modified Ashworth Scale, FIM, Berg Balance Scale, 10-m walk speed) could most simply predict discharge walking ability (10-m walk speed). A logistic regression determined the likelihood of a participant achieving household (<0.4m/s) versus community (≥0.4 –0.8m/s; >0.8m/s) ambulation at the time of discharge. Validity of the results was evaluated on a second sample of participants. Main Outcome Measure Discharge 10-m walk speed. Results Admission Berg Balance Scale and FIM walk item scores explained most of the variance in discharge walk speed. The odds ratio of achieving only household ambulation at discharge was 20 (95% confidence interval [CI], 6 – 63) for sample 1 and 32 (95% CI, 10 –96) for sample 2 when the combination of having a Berg Balance Scale score of ≤20 and a FIM walk item score of 1 or 2 was present. Conclusions A Berg Balance Scale score of ≤20 and a FIM walk item score of 1 or 2 at admission indicates that a person with stroke is highly likely to only achieve household ambulation speeds at discharge from an IRF.

Objective 1) To examine clinician adherence to a standardized assessment battery across settings (acute hospital, IRF, outpatient facility), professional disciplines (PT, OT, SLP), and time of assessment (admission, discharge/monthly), and 2) evaluate how specific implementation events affected adherence. Design Retrospective cohort study Setting Acute hospital, IRF, outpatient facility with approximately 118 clinicians (PT, OT, SLP). Participants 2194 participants with stroke who were admitted to at least one of the above settings. All persons with stroke undergo standardized clinical assessments. Interventions N/A Main Outcome Measure Adherence to Brain Recovery Core assessment battery across settings, professional disciplines and time. Visual inspections of 17 months of time-series data were conducted to see if the events (e.g. staff meetings) increased adherence ≥ 5% and if so, how long the increase lasted. Results Median adherence ranged from 0.52 to 0.88 across all settings and professional disciplines. Both the acute hospital and IRF had higher adherence than the outpatient setting (p ≤ .001) with PT having the highest adherence across all three disciplines (p < .004). Of the 25 events conducted across the 17 month period to improve adherence, 10 (40%) resulted in a ≥ 5% increase in adherence the following month, with 6 services (60%) maintaining their increased level of adherence for at least one additional month. Conclusion Actual adherence to a standardized assessment battery in clinical practice varied across settings, disciplines and time. Specific events increased adherence 40% of the time with gains maintained for greater than a month in 60%.

This Special Interest article describes a multidisciplinary, interinstitutional effort to build an organized system of stroke rehabilitation and outcomes measurement across the continuum of care. This system is focused on a cohort of patients who are admitted with the diagnosis of stroke to our acute facility, are discharged to inpatient and/or outpatient rehabilitation at our free-standing facility, and are then discharged to the community. This article first briefly explains the justification, goals, and purpose of the Brain Recovery Core system. The next sections describe its development and implementation, with details on the aspects related to physical therapy. The article concludes with an assessment of how the Brain Recovery Core system has changed and improved delivery of rehabilitation services. It is hoped that the contents of this article will be useful in initiating discussions and potentially facilitating similar efforts among other centers.

The purpose of this study was to investigate which physical therapy assessments administered at admission to an inpatient rehabilitation facility (IRF) could predict discharge walking ability in a local population of people with stroke. The sample consisted of 111 IRF participants with stroke who consented to have records stored in the Brain Recovery Core database between January 2010 and January 2011. Independent variables from the admission assessment included: lower extremity Motricity Index, somatosensation, Modified Ashworth Scale, Functional Independence Measure (FIM) locomotor item, Berg Balance Scale, walking speed, age, history of previous stroke, and time from stroke onset to IRF assessment. The dependent variable was discharge walking ability, defined as walking speed on the 10 m Walk Test. Correlational analyses examined relationships with and between the admission variables and discharge walking ability. Step-wise multiple regression was used to determine the most parsimonious combination of variables that could explain variance in discharge walking ability. Logistic regression was used to determine the likelihood of achieving household (< 0.4 m/s) versus community (≥ 0.4 - 0.8, > 0.8 m/s) ambulation categories. Results from the stepwise model indicated that 2 admission variables, Berg Balance score and FIM locomotor score, explained 80% of the variance in discharge walking ability. For the logistic model, the odds ratio of achieving only household ambulation at discharge was 20 (95%CI: 6-63) when the combination of having a Berg Balance < 20 and a FIM locomotor score of 1 or 2 was present. The logistic model correctly classified 92% of subjects achieving only household ambulation and 64% of subjects achieving better than household ambulation. These findings suggest that performance on the Berg Balance Scale and the FIM locomotor item at admission to an IRF can explain most of the variance in discharge walking ability. Having the combination of a Berg Balance score < 20 and a FIM locomotor score of 1 or 2 at admission indicates that a person is highly likely to be only a household ambulator at discharge from the IRF. Knowing at the time of IRF admission that a person with stroke is not likely to achieve limited community or community ambulation status will allow for earlier discharge planning with respect to needed assistance at home, durable-medical equipment, and home modifications.