"Home or Hospital for Stroke Rehabilitation? Results of a Randomized Controlled Trial: 
Health Outcomes at Six Months"

Craig Anderson, Ph.D., Sally Rubenach, MSocSc., Cliona Nii Mhurchu, Ph.D., Michael Clark, Ph.D., Carol Spencer, BAppSc (OT), & Adrian Winsor, FAFRM

Traditionally, acute hospital care and rehabilitation has been the treatment of choice for patients recovering from stroke and community services have not been a primary focus of the care plan. Critics note that one disadvantage of this approach is that the needs of both patients and family caregivers as they evolve in the long-term may not be addressed during a hospital stay. Further, some argue that the longer-term hospital stays common after strokes may, in fact, foster states of depression and learned dependency which can adversely affect outcome. In contrast, advocates of home-based stroke rehabilitation, which strives to minimize time spent in a hospital facility, suggest that this approach is preferable because it focuses more on long-term outcomes, reduces the risks associated with inpatient care, satisfies patient choice and saves in direct costs.

This research compared the effectiveness of acute hospital care versus early hospital discharge and a home-based rehabilitation program for stroke patients. Subjects were 86 patients (mean age=75 years) who presented with strokes at either of two teaching hospitals in suburban Australia. Forty-two patients received early hospital discharge and home-based rehabilitation; 44 patients received conventional rehabilitation in a hospital setting.

Home-based rehabilitation was conducted by specialists in various disciplines (e.g. physical therapists, occupational therapists, speech therapists, social workers, etc.) and unique treatment programs were designed for each subject. Treatment sessions occurred in the subjects' homes and emphasis was placed on self-learning and adjustment to disability. Those subjects receiving traditional hospital-based acute care were treated by a similar team of practitioners while discharge-planning and follow-up care were conducted according to usual policies.

Six-months later, no significant differences were found between subjects in the two groups on medical status, re-admission to medical facilities or measures of health-related quality of life. Interestingly, however, subjects in both groups reported dissatisfaction with their understanding of stroke and with the information they had received from their healthcare professionals during the preceding six months.

The only significant differences found between the two groups were: 1) actual length of hospital stay: 30 days on average for subjects in the acute-care groups versus 15 days for subjects in the home-based rehabilitation group; and 2) caregiver mental health. Six months after the date of onset, caregivers of subjects in the home based rehabilitation group reported lower scores on mental health measures than did their counterparts in the traditional care group. The authors note, however, that even these lower scores reported by caregivers of subjects in the home-based program compared well with the mental health scores of the population as a whole and they attach minimal practical significance to this finding.

The authors conclude that a home-based program of rehabilitation for stroke patients can significantly shorten length of stay in a hospital facility without compromising patient safety or functional outcomes, and they advocate further exploration of such treatment options.

Article abstracted by Glen E. Heiss, Ph.D., Staff Psychologist at Jamaica Hospital Medical Center Department of Physical Medicine and Rehabilitation