Journal-based CME article| Volume 94, ISSUE 4, P622-629, April 2013

Does Postacute Care Site Matter? A Longitudinal Study Assessing Functional Recovery After a Stroke

Published:November 05, 2012DOI:



      To determine the impact of postacute care site on stroke outcomes.


      Prospective cohort study.


      Four northern California hospitals that are part of a single health maintenance organization.


      Patients with stroke (N=222) enrolled between February 2008 and July 2010.


      Not applicable.

      Main Outcome Measure

      Baseline and 6-month assessments were performed using the Activity Measure for Post Acute Care (AM-PAC), a test of self-reported function in 3 domains: Basic Mobility, Daily Activities, and Applied Cognition.


      Of the 222 patients analyzed, 36% went home with no treatment, 22% received home health/outpatient care, 30% included an inpatient rehabilitation facility (IRF) in their care trajectory, and 13% included a skilled nursing facility (but not IRF) in their care trajectory. At 6 months, after controlling for important variables such as age, functional status at acute care discharge, and total hours of rehabilitation, patients who went to an IRF had functional scores that were at least 8 points higher (twice the minimally detectable change for the AM-PAC) than those who went to a skilled nursing facility in all 3 domains and in 2 of 3 functional domains compared with those who received home health/outpatient care.


      Patients with stroke may make more functional gains if their postacute care includes an IRF. This finding may have important implications as postacute care delivery is reshaped through health care reform.


      List of abbreviations:

      ACO (accountable care organization), AM-PAC (Activity Measure for Post Acute Care), HH (home health care), IRF (inpatient rehabilitation facility), mCharlson (modified Charlson), MDC (minimal detectable change), mNIHSS (modified National Institutes of Health Stroke Scale), mRankin (modified Rankin), OP (outpatient), PPACA (Patient Protection and Affordable Care Act of 2010), SNF (skilled nursing facility)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Mukherjee D.
        • Patil C.G.
        Epidemiology and the global burden of stroke.
        World Neurosurg. 2011; 76: S85-S90
      1. Centers for Disease Control and Prevention. Heart disease and stroke prevention. Addressing the nation's leading killers: at a glance 2011. Available at: Accessed November 29, 2012.

        • Dobkin B.H.
        Clinical practice. Rehabilitation after stroke.
        N Engl J Med. 2005; 352: 1677-1684
      2. Gresham GE, Duncan PW, Stason WB, et al. Post-Stroke Rehabilitation. Clinical Practice Guideline, No. 16. U.S. Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research; Rockville: 1995. AHCPR Publication No. 95-0662.

        • Duncan P.W.
        • Zorowitz R.
        • Bates B.
        • et al.
        Management of adult stroke rehabilitation care: a clinical practice guideline.
        Stroke. 2005; 36: e100-e143
        • Foley N.
        • Pereira S.
        • Salter K.
        • Meyer M.
        • McClure J.A.
        • Teasell R.
        Are recommendations regarding inpatient therapy intensity following acute stroke really evidence-based?.
        Top Stroke Rehabil. 2012; 19: 96-103
        • Govan L.
        • Weir C.J.
        • Langhorne P.
        Organized inpatient (stroke unit) care for stroke.
        Stroke. 2008; 39: 2402-2403
        • Ward D.
        • Drahota A.
        • Gal D.
        • Severs M.
        • Dean T.P.
        Care home versus hospital and own home environments for rehabilitation of older people.
        Cochrane Database Syst Rev. 2008; : CD003164
      3. Stroke Unit Trialists' Collaboration. Organised inpatient (stroke unit) care for stroke.
        Cochrane Database Syst Rev. 2007; : CD000197
        • Boninger J.
        • Gans B.
        • Chan L.
        The Patient Protection and Affordable Care Act: potential effects on physical medicine and rehabilitation.
        Arch Phys Med Rehabil. 2012; 93: 929-934
      4. Gage B, Morley M, Smith L, et al. U.S. Dept of Health and Human Services Centers for Medicare & Medicaid Services (CMS). Post acute care payment reform demonstration (PAC-PRD). 2012. Available at: Accessed November 29, 2012.

        • Kane K.
        • Andary M.T.
        • Turk M.
        • Goldberg G.
        Cost-effectiveness in stroke rehab.
        Arch Phys Med Rehabil. 1996; 77 (author reply 522-3): 521
        • Kramer A.M.
        • Steiner J.F.
        • Schlenker R.E.
        • et al.
        Outcomes and costs after hip fracture and stroke. A comparison of rehabilitation settings.
        JAMA. 1997; 277: 396-404
        • Haley S.
        • Andres P.
        • Coster W.
        • Kosinski M.
        • Ni P.
        • Jette A.
        Short-form activity measure for post-acute care.
        Arch Phys Med Rehabil. 2004; 85: 649-660
        • Andres P.L.
        • Black-Schaffer R.M.
        • Ni P.
        • Haley S.M.
        Computer adaptive testing: a strategy for monitoring stroke rehabilitation across settings.
        Top Stroke Rehabil. 2004; 11: 33-39
        • Siebens H.
        • Andres P.L.
        • Pengsheng N.
        • Coster W.J.
        • Haley S.M.
        Measuring physical function in patients with complex medical and postsurgical conditions: a computer adaptive approach.
        Am J Phys Med Rehabil. 2005; 84: 741-748
        • Haley S.M.
        • Coster W.J.
        • Andres P.L.
        • et al.
        Activity outcome measurement for postacute care.
        Med Care. 2004; 42: I49-I61
        • Haley S.M.
        • Ni P.
        • Jette A.M.
        • et al.
        Replenishing a computerized adaptive test of patient-reported daily activity functioning.
        Qual Life Res. 2009; 18: 461-471
        • Jette A.M.
        • Haley S.M.
        • Tao W.
        • et al.
        Prospective evaluation of the AM-PAC-CAT in outpatient rehabilitation settings.
        Phys Ther. 2007; 87: 385-398
        • Jette A.M.
        • Ni P.
        • Rasch E.K.
        • et al.
        Evaluation of patient and proxy responses on the activity measure for postacute care.
        Stroke. 2012; 43: 824-829
        • Andres P.L.
        • Haley S.M.
        • Ni P.S.
        Is patient-reported function reliable for monitoring postacute outcomes?.
        Am J Phys Med Rehabil. 2003; 82: 614-621
        • Haley S.M.
        • Ni P.
        • Coster W.J.
        • Black-Schaffer R.
        • Siebens H.
        • Tao W.
        Agreement in functional assessment: graphic approaches to displaying respondent effects.
        Am J Phys Med Rehabil. 2006; 85: 747-755
        • Meyer B.C.
        • Hemmen T.M.
        • Jackson C.M.
        • Lyden P.D.
        Modified National Institutes of Health Stroke Scale for use in stroke clinical trials: prospective reliability and validity.
        Stroke. 2002; 33: 1261-1266
        • Banks J.L.
        • Marotta C.A.
        Outcomes validity and reliability of the modified Rankin scale: implications for stroke clinical trials: a literature review and synthesis.
        Stroke. 2007; 38: 1091-1096
        • Charlson M.E.
        • Pompei P.
        • Ales K.L.
        • MacKenzie C.R.
        A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
        J Chronic Dis. 1987; 40: 373-383
        • Buntin M.B.
        • Colla C.H.
        • Deb P.
        • Sood N.
        • Escarce J.J.
        Medicare spending and outcomes after postacute care for stroke and hip fracture.
        Med Care. 2010; 48: 776-784
        • Deutsch A.
        • Granger C.V.
        • Heinemann A.W.
        • et al.
        Poststroke rehabilitation: outcomes and reimbursement of inpatient rehabilitation facilities and subacute rehabilitation programs.
        Stroke. 2006; 37: 1477-1482
        • Kane R.L.
        • Chen Q.
        • Blewett L.A.
        • Sangl J.
        Do rehabilitative nursing homes improve the outcomes of care?.
        J Am Geriatr Soc. 1996; 44: 545-554
        • DeJong G.
        • Hsieh C.H.
        • Gassaway J.
        • et al.
        Characterizing rehabilitation services for patients with knee and hip replacement in skilled nursing facilities and inpatient rehabilitation facilities.
        Arch Phys Med Rehabil. 2009; 90: 1269-1283
        • Chan L.
        The state-of-the-science: challenges in designing postacute care payment policy.
        Arch Phys Med Rehabil. 2007; 88: 1522-1525