Exploring the Inclusion of Person-Centered Care Domains in Stroke Transitions of Care Interventions: A Scientific Statement From the American Heart Association.

BACKGROUND: Health care teams along the stroke recovery continuum have a responsibility to support care transitions and return to the community. Ideally, individualized care will consider patient and family preferences, best available evidence, and health care professional input. Person-centered care can improve patient-practitioner interactions through shared decision-making in which health professionals and institutions are sensitive to those for whom they provide care. However, it is unclear how the concepts of person-centered care have been described in reports of stroke transitional care interventions. METHODS: A secondary analysis of a systematic review and meta-analysis was undertaken. We retrieved all included articles (n=17) and evaluated the extent to which each intervention explicitly addressed 7 domains of person-centered care: alignment of care with patients' values, preferences, and needs; coordination of care; information and education; physical comfort; emotional support; family and friend involvement; and smooth transition and continuity of care. RESULTS: Most of the articles included some aspects of person-centeredness; we found that certain domains were not addressed in the descriptions of transitional care interventions, and no articles mentioned all 7 domains of person-centered care. We identified 3 implications for practice and research: (1) delineating person-centered care components when reporting interventions, (2) elucidating social and cultural factors relevant to the study sample and intervention, and (3) clearly describing the role of family and nonmedical support in the intervention. CONCLUSIONS: There is still room for greater consistency in the reporting of person-centeredness in stroke transitions of care interventions, despite a long-standing definition and conceptualization of person-centered care in academic and clinically focused literature.

Mild Traumatic Brain Injuries and Risk for Affective and Behavioral Disorders.

OBJECTIVES: Recent studies document an association between mild traumatic brain injuries (mTBIs) in children and postinjury psychiatric disorders. However. these studies were subject to limitations in the design, lack of long-term follow-up, and poorly defined psychiatric outcomes. This study determines the incidence and relative risk of postinjury new affective and behavior disorders 4 years after mTBIs. METHODS: A cohort study of mTBI cases and matched comparisons within an integrated health care system. The mTBI group included patients ≤17 years of age, diagnosed with mTBI from 2000 to 2014 (N = 18 917). Comparisons included 2 unexposed patients (N = 37 834) per each mTBI-exposed patient, randomly selected and matched for age, sex, race/ethnicity, and date of medical visit (reference date to mTBI injury). Outcomes included a diagnosis of affective or behavioral disorders in the 4 years after mTBI or the reference date. RESULTS: Adjusted risks for affective disorders were significantly higher across the first 3 years after injury for the mTBI group, especially during the second year, with a 34% increase in risk. Adjusted risks for behavioral disorders were significant at years 2 and 4, with up to a 37% increase in risk. The age group with the highest risk for postinjury affective and behavioral disorders was 10- to 13-year-old patients. CONCLUSIONS: Sustaining an mTBI significantly increased the risks of having a new affective or behavioral disorder up to 4 years after injury. Initial and ongoing screening for affective and behavior disorders following an mTBI can identify persistent conditions that may pose barriers to recovery.

The preparedness assessment for the transition home after stroke predicts key domains of caregiver health.

BACKGROUND: Caregivers of stroke survivors often experience adverse health effects due to poor preparation. OBJECTIVES: We evaluate the concurrent and predictive validity of the Preparedness Assessment for the Transition Home after Stroke (PATH-s) family caregiver assessment tool relative to important domains of caregiver health and stroke survivor outcomes. METHODS: A convenience sample of caregivers (N = 183) was assessed on several health-related quality of life instruments prior to stroke survivor discharge (T1), and at 30-days (T2) and 90-days (T3) post-discharge. RESULTS: Caregivers completed assessments at T1 (N = 183), T2 (N = 116, 63%), and T3 (N = 97, 53%). At T1, the PATH-s demonstrated concurrent validity with depressive symptoms (r = -0.26, p < .001), global health (r = 0.45 p < .001) and activation (r = 0.34, p < .001). The PATH-s also has predicted improvements in T2 outcomes including depressive symptoms (radj = -0.21, p < .05), global health (radj = 0.30, p < .01), perceived stress (radj = -0.30, p < .01), activation (radj = 0.21, p < .05), caregiving-specific health-related quality of life (r = 0.23, p < .05), and caregiver strain (r = -0.36, p < .001). At T3, higher scores on the PATH-s were a significant predictor for improvements in activation (radj = 0.24, p < .05). CONCLUSION: The PATH-s demonstrates good concurrent and predictive validity and predicts important domains relevant to caregiver well-being. This can be used to identify gaps in caregiver preparedness so interventions can be tailored to optimize the transition home and mitigate adverse effects of caregiving.

Prevalence of depression and anxiety disorders following mild traumatic brain injury.

BACKGROUND: Previous studies have identified an association between traumatic brain injuries and the development of psychiatric disorders in general. However, these studies were subject to limitations that demonstrate the need for a study of a large, clearly defined mild traumatic brain injury (mTBI) population within an integrated healthcare system. OBJECTIVE: To determine the prevalence and relative risk of postinjury affective disorders over 4 years following mTBI. DESIGN: Cohort study of mTBI cases and matched controls, over a 4-year period. SETTING: An integrated healthcare delivery system in California. PATIENTS: A total of 9428 adult health plan members diagnosed with mTBI from 2000-2007 and enrolled in the year before injury, during which no TBI was ascertained. Control participants included 18,856 individuals selected based on the following criteria: Two unexposed health plan members per each mTBI-exposed patient were randomly selected and individually matched for age, gender, race/ethnicity, and medical comorbidities. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: A diagnosis of affective disorder (depressive, anxiety, and adjustment disorders) in the 4 years after mTBI or the reference date, determined according to the International Classification of Diseases, Ninth Revision, Clinical Modification as well as the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. RESULTS: Affective disorders were most prominent during the first 12 months with 23% following mTBI and 14% in the control group. Four-year aggregate adjusted odds ratios for having an affective disorder following mTBI were 1.2 (95% CI: 1.1, 1.2; p < .001) and 1.5 (95% CI: 1.5, 1.6; p < .001) for patients with and without prior affective disorders, respectively. CONCLUSION: mTBI was associated with a significantly increased risk of having subsequent affective disorders. Screening for and addressing affective disorders at earlier stages following the injury is an important step to avoid persisting conditions that may pose a barrier to full recovery.

Improving Caregiver Health through Systematic Assessment and a Tailored Plan of Care.

Caregivers often experience strain and negative effects on their well-being. We tested the effects of a caregiver assessment and tailored care plan for caregivers of patients transitioning home from an inpatient rehabilitation facility (IRF), a study involving two groups: usual care (n = 225) (preimplementation) and intervention (postimplementation) (n = 215). Caregivers in the intervention group were assessed using the 25-item self-reported Preparedness Assessment for the Transition Home during the IRF stay. A tailored care plan was implemented in response to the assessment. Caregivers in both groups completed the Modified Caregiver Strain Index and Global Health Scale at 30- and 90-day postdischarge. After adjusting for baseline and demographics, caregivers in the intervention group reported lower strain (p < .01) and better overall health (p < .05) at 30-day post-IRF discharge, relative to usual care. Implementing a systematic caregiver assessment and tailored care plan in the IRF may mitigate the adverse effects of caregiving.

Nursing's Role in Successful Stroke Care Transitions Across the Continuum: From Acute Care Into the Community.

Facilitating successful care transitions across settings is a key nursing competency. Although we have achieved improvements in acute stroke care, similar advances in stroke care transitions in the postacute and return to community phases have lagged far behind. In the current delivery system, care transitions are often ineffective and inefficient resulting in unmet needs and high rates of unnecessary complications and avoidable hospital readmissions. Nurses must use evidence-based approaches to prepare stroke survivors and their family caregivers for postdischarge self-management, rehabilitation, and recovery. The purpose of this article is to provide evidence on the important nursing roles in stroke care and transition management across the care continuum, discuss cross-setting issues in stroke care, and provide recommendations to leverage nursing's impact in optimizing outcomes for stroke survivors and their family unit across the continuum. To optimize nursing's influence in facilitating safe, effective, and efficient care transitions for stroke survivors and their family caregivers across the continuum we have the following recommendations (1) establish a system of coordinated and seamless comprehensive stroke care across the continuum and into the community; (2) implement a stroke nurse liaison role that provides consultant case management for the episode of care across all settings/services for improved consistency, communication and follow-up care; (3) implement a validated caregiver assessment tool to systematically assess gaps in caregiver preparedness and develop a tailored caregiver/family care plan that can be implemented to improve caregiver preparedness; (4) use evidence-based teaching and communication methods to optimize stroke survivor/caregiver learning; and (5) use technology to advance stroke nursing care. Nurses must leverage their substantial influence over the health care delivery system to achieve these improvements in stroke care delivery to improve the health and lives of stroke survivors and their families.

COVID-19 and Inpatient Rehabilitation Nursing Care: Lessons Learned and Implications for the Future.

ABSTRACT: The SARS-CoV-2 coronavirus (COVID-19) pandemic is impacting post-acute inpatient rehabilitation nursing practice from preadmission assessment to inpatient care delivery and transition planning. Patients with disability following COVID-19 require interventions to address respiratory, cardiovascular, neurological, musculoskeletal, and psychosocial issues. The pandemic has resulted in changes to program structures and how inpatient rehabilitation facilities approach family caregiver engagement amidst visitation restrictions. Technology solutions can be utilized to reduce the patient and their family's feelings of isolation and support caregiver preparation for discharge. Nurse leaders are essential in supporting staff during this crisis through authentic presence and providing resources and training. Rehabilitation nurses are key in helping patients and families manage rehabilitation and the aftermath of COVID-19 to restore optimal functioning. In this clinical consultation, we synthesize insights learned from the COVID-19 responses at three inpatient rehabilitation facilities. We describe the impact of rehabilitation nursing interventions to improve outcomes for patients with COVID-19 and their caregivers.

Psychometric Properties of the Preparedness Assessment for the Transition Home After Stroke Instrument.

PURPOSE: The aim of this study was to evaluate psychometric properties of the Preparedness Assessment for the Transition Home After Stroke (PATH-s), a novel instrument to assess stroke caregiver commitment and capacity. The PATH-s instrument can be obtained at www.rehabnurse.org/pathtool. DESIGN: The design of this study is cross-sectional. METHODS: The PATH-s, the Preparedness for Caregiving Scale (PCS), the Patient Health Questionnaire, the Perceived Stress Scale, and the Global Health Scale were self-reported from a convenience sample of caregiver-stroke survivor dyads (n = 183) during inpatient rehabilitation. RESULTS: Exploratory factor analysis revealed eight factors underlying the PATH-s structure. The PATH-s Cronbach's alpha of .90 demonstrated criterion-related validity with the PCS (r = .79, p < .01). Both the PATH-s and the PCS were negatively correlated with the Patient Health Questionnaire (r = -.26 and -.27, respectively; p < .01) and the Perceived Stress Scale (r = -.12 and -.15, respectively; p > .05) and positively correlated with the Global Health Scale (r = -.46 and .46, respectively; p < .01), indicating convergent validity. CONCLUSIONS: The PATH-s demonstrates excellent internal consistency and satisfactory criterion-related and convergent validity. CLINICAL RELEVANCE: The PATH-s may be used to assess the risk/needs of caregivers over time.

Using the Preparedness Assessment for the Transition Home After Stroke Instrument to Identify Stroke Caregiver Concerns Predischarge: Uncertainty, Anticipation, and Cues to Action.

PURPOSE: The aim of the study was to better understand caregivers' concerns about long-term implications of stroke and the caregiving role after completing the Preparedness Assessment for the Transition Home After Stroke (PATH-s). DESIGN/METHODS: In this qualitative study, cognitive interviews were conducted with 20 stroke caregivers who completed the PATH-s tool as part of an instrument validation study. Data were analyzed for salient themes related to their perceptions about stroke and the caregiving role. FINDINGS: Interviews yielded robust narrative data describing how the PATH-s items aided caregivers in recognizing potential issues and concerns about stroke and the caregiving role. Caregivers experienced uncertainty about the long-term stroke prognosis, which provoked anticipation and cues to action to begin addressing their concerns. CONCLUSIONS/CLINICAL RELEVANCE: Completing the PATH-s helped caregivers identify concerns regarding the long-term implications of stroke and their caregiving role. It may serve as an important assessment tool to assist rehabilitation nurses to better understand and address caregiver needs predischarge.

Development of an Instrument to Assess Stroke Caregivers' Readiness for the Transition Home.

PURPOSE: The study purpose was to develop a measure to assess stroke caregivers' commitment and capacity to assume the caregiving role prior to discharge. DESIGN: Participants were caregivers of stroke survivors in an inpatient rehabilitation facility. METHODS: A sequential, multimethod approach, which included item generation from qualitative data, review of items by expert clinicians, cognitive interviews to determine response format (n = 22), and item clarity (n = 20), and an analysis of pilot data were utilized. FINDINGS: Cognitive interviewing provided information to improve item clarity. CONCLUSION: This instrument development approach resulted in the Preparedness Assessment for the Transition Home After Stroke (PATH-s), a 26-item self-report instrument. The PATH-s represents the domains of the Model of Caregiver Readiness, upon which the instrument was developed. CLINICAL RELEVANCE: The PATH-s, once further validated, may guide healthcare providers in the development of tailored care plans to address identified gaps and better prepare caregivers for the transition home.

Nurse Author: Who Me? Yes, You!

BACKGROUND AND PURPOSE: Potential nurse authors may find writing a challenge, including managing the publication process from getting started through submission to revision of the work and its acceptance. This special article presents strategies to help inexperienced writers develop and hone skills for journal publication. POTENTIAL PUBLICATION STRATEGIES: Tips discussed here that may lead to manuscript acceptance include selecting a topic of interest, using motivational self-talk approaches and structuring time to write, choosing coauthors, targeting a journal for submission, writing strong sentences in active voice, developing a structured abstract, using correct citation and reference formats, understanding reviews and resubmitting the manuscript, and keeping momentum to produce continued writing results. Practical writing hints are also suggested for inexperienced writers. RELEVANCE AND CONCLUSION: These strategies can help guide nurse writers in planning, navigating the system, and finding success as a published author.

Determining the Needs of Family Caregivers of Stroke Patients During Inpatient Rehabilitation Using Interview, Art, and Survey.

The purpose of this study is to explore the needs of family members at the bedside of stroke patients (n = 12) admitted to an inpatient rehabilitation facility (IRF). Family members' needs were determined through semistructured interviews, "Draw a Bridge" art therapy technique, and the Family Inventory of Needs. Family members described a family-centered approach to care that addressed the following needs: assistance with preparing for discharge, staff caring for family members, communication about the plan of care and what to expect postdischarge, and trusting the care provided by IRF staff. Art therapy revealed that stroke was a crisis with many unmet needs for the interviewer to explore. Descriptive statistical analysis of the Family Inventory of Needs revealed that both met and unmet needs were consistent with the interviews and the interpretations of the drawings. These findings inform the need for interventions during IRF to enhance communication, support, and effective caregiver education amidst the crisis of stroke.

Length of Stay at Inpatient Rehabilitation Facility and Stroke Patient Outcomes.

PURPOSE: To examine the association of inpatient rehabilitation facility (IRF) length of stay (LOS) with stroke patient outcomes. DESIGN: A secondary data analysis of the Uniform Data System for Medical Rehabilitation database. METHODS: Stroke patients discharged from IRFs in the United States between 2009 and 2011 were identified and divided into mild (n = 639), moderate (n = 2,065), and severely (n = 2,077) impaired groups. Study outcomes included cognition and motor functional gains measured by the Functional Independence Measure (FIM) instrument and discharge to the community. FINDINGS: The average LOS was 8.9, 13.9, and 22.2 days for mild, moderate, and severely impaired stroke patients, respectively. After controlling for FIM admission and other important covariates, a longer LOS was associated with a modest increase in cognition gain (ß = 0.038, p = .0045) for the moderately impaired patients, and a modest increase in cognition (ß = 0.13, p < .0001) and motor gains (ß = 0.25, p < .0001) as well as a tendency for discharge to the community (OR = 1.01, 95% CI = 1.00-1.02) among the severely impaired patients. However, a longer LOS showed a negative association with functional gains among the mildly impaired patients as well as discharge to community for both mild and moderately impaired patients. CONCLUSION: The association of IRF LOS and patient outcomes varied by stroke impairment severity, positively for more severely impaired patients and negatively for mildly impaired patients. CLINICAL RELEVANCE: The study provides evidence for the care of stroke patients at the IRF setting.

Early inpatient rehabilitation admission and stroke patient outcomes.

OBJECTIVE: The aim of this study was to examine the associations of onset days, time from stroke onset to inpatient rehabilitation facility (IRF) admission, and patient outcomes (FIM gain, discharge destination, and IRF length of stay), using nationally representative data. DESIGN: A secondary data analysis was conducted on a random sample of stroke patients discharged from IRFs in the United States between 2009 and 2011, including mildly (n = 649), moderately (n = 2185), and severely (n = 2390) impaired patients. RESULTS: The study sample had a median of onset days of 5.5, with an interquartile range of 4-9. With the use of 15-365 days as reference, the severely impaired patients had a higher cognition gain (P < 0.01) and were more likely to be discharged to the community (odds ratio, 1.45; 95% confidence interval, 1.12-1.87) when admitted within 7 days, a greater motor gain when admitted within 14 days (P < 0.01), and a lower risk for acute hospital transfer when admitted 3-7 days (odds ratio, 0.62; 95% confidence interval, 0.43-0.90). The moderately impaired patients had a greater motor gain when admitted within 7 days (P < 0.01). Early IRF admission was also associated with a shorter length of stay. CONCLUSIONS: Earlier IRF admission was beneficial among severely and moderately impaired patients. IRF admission within 7 days is recommended for stroke patients who achieved medical stability.