Access to rehabilitation is a “lifeline” for patients that needs to be protected and preserved to ensure their recovery.
A patient’s ability to obtain timely and adequate access to rehabilitation services after a stroke is often dictated by racial, ethnic, socioeconomic, and geographic issues rather than their own needs, according to a joint policy statement from the American Heart Association (AHA) and the American Stroke Association (ASA).
Committee chair Nneka L. Ifejika, MD, MPH (University of Texas Southwestern Medical Center, Dallas), noted to TCTMD that the majority of the committee members who authored the statement are active practitioners of stroke rehabilitation and recovery who have become increasingly concerned about the widening gaps they see in access to postacute care (PAC) services. The policy statement represents the first time the AHA and ASA have taken an advocacy approach to address these issues.
“Ideally, stroke rehabilitation starts in the hospital and there’s a good continuity of care to the postacute realm,” Ifejika added. Whether the patient transitions to inpatient rehab, a skilled nursing facility, an outpatient rehab center, or even telerehabilitation, the committee says there’s no standardized framework in place to ensure equitable continuity of care after a stroke.
In the policy statement published recently in Stroke, Ifejika and colleagues pinpoint some of the major gaps and issue a call for action to preserve and improve access to stroke rehab, which they term “a lifeline of hope” not just for patients, but also for their families, caregivers, and communities.
“We’ve made all these wonderful strides in acute stroke treatment, but we’re not making similar strides in stroke rehabilitation and recovery,” Ifejika said.
Unlike cardiac rehab, which is focused on helping the patient improve functional endurance after an acute cardiac event, stroke rehab can be directed at more subtle issues that nevertheless interfere with patients getting back to daily routines like self-care and work and regaining their sense of independence and identity.
“Patients may have cognitive impairments, they may have sensory impairments, they may have motor impairments,” Ifejika noted. “They may have difficulty with depression or anxiety, and so it’s a more of a multifactorial rehabilitation that we’re addressing after a stroke.”
Payers, Unmet Needs, and Advocacy
In looking at what’s driving the types of poststroke care that patients receive, the committee notes that among other things, partnerships among health corporations, hospitals, health systems, and physician groups can have a big impact.
“Such partnerships can result in a conflict of financial interest between the needs of these organizations and the patient’s clinical needs,” they write. “In some areas of the United States, the reach of large healthcare systems or conglomerates limits access to PAC options.” They also cite a lack of transparency regarding the factors used to make determinations on behalf of patients about their options.
According to Ifejika and colleagues, a congressional subcommittee recently investigated three Medicare Advantage programs that they say disproportionately select against patients having access to PAC.
The US Senate Permanent Subcommittee on Investigations detailed in a 2024 report how all three programs—UnitedHealthcare, Humana, and CVS—use artificial intelligence (AI), predictive models, and automation to deny access to PAC. Using these methods, the subcommittee said, Humana’s denial rate for long-term acute hospitals increased by 54% between 2020 and 2022, UnitedHealthcare’s prior authorization denial rate for PAC increased from 10.9% in 2020 to 22.7% in 2022, and CVS admitted to saving $660 million in 2018 by denying prior authorizations submitted for Medicare Advantage beneficiaries for inpatient PAC.
Patients tend to get lost to follow-up because they look normal, when in fact they aren’t. Nneka L. Ifejika
Delving into unmet needs, the new document’s committee says stroke survivors and their families need more thorough education during the acute hospitalization about all PAC options and should be provided with consistent follow-up at 30 and 90 days that includes documentation of modified Rankin Scale score. In addition to addressing the needs of the patient, PAC can also help family members who are becoming first-time caregivers to understand a host of things they will need to do, from assisting in activities of daily living to preventing falls.
Throughout the policy statement, Ifejika and colleagues note the importance of advocacy to improve the stroke rehabilitation system and give patients and caregivers information they need to make informed decisions. That includes developing performance measures as well as public policy guidance to ensure that the PAC matches the needs of all patients, including those who are under- or uninsured so could get lost to care and follow-up once they leave the hospital.
Among the priorities that the committee sees as being crucial going forward are:
- More resources for the study of stroke rehab with research questions that directly reflect practical, day-to-day challenges of clinicians, families, and patients
- An open-access surveillance system for collecting data across the full spectrum of stroke type, severity, demographics, health systems, hospitals, and payers
- Better understanding of how variability in rehab care is influenced by health systems, hospitals, insurance, and alternative payment models
- A comprehensive inventory of coverage policies of all major payers/insurers in the US and field surveys of discharge planners at acute hospitals to uncover barriers to PAC recommendations
- Comparative effectiveness and cost-effectiveness studies of different rehabilitation strategies
- Expansion of clinical training programs to improve understanding of patient, family, and caregiver needs after discharge, including the role of social determinants of health as they relate to medical care and access to community resources for PAC
- More research into the transition from hospital to home
Importantly, Ifejika said, there is still much to be learned not only about which services patients need after a stroke, but when they need them, because each recovery is different and may not be linear.
“There has to be an understanding that when they’re in the hospital, they may present as having no additional neurologic deficits, or they may present as being normal. You haven’t seen them out in the community yet, so you really don’t know whether they have additional impairments,” she said. “Patients tend to get lost to follow-up because they look normal, when in fact they aren’t. Unfortunately, that contributes to increased costs because they [may not be] able to go back to work . . . or someone has to stay home or a caregiver has to be hired.”