Original research| Volume 101, ISSUE 7, P1190-1198, July 2020

Are Stroke Survivors Discharged to the Recommended Postacute Setting?

Published:April 06, 2020DOI:


      • Among participating United States hospitals, most stroke survivors were discharged to:
      • The post-acute care destination deemed most appropriate by discharge planners and physical therapists.
      • Deciding to discharge patients to less intensive care settings than preferred was:
      • Mostly attributed to patient or family preference.
      • Sparingly attributed to insurance or other limitations.



      To examine the processes and barriers involved in providing postdischarge stroke care.


      Prospective study of discharge planners’ (DP) and physical therapists’ (PT) interpretation of factors contributing to patients’ discharge destination.


      Twenty-three hospitals in the northeastern United States.


      After exclusions, data on patients (N=427) hospitalized with a primary diagnosis of stroke between May 2015 and November 2016 were examined. Of the patients, 45% were women, and the median age was 71 years. DPs and PTs caring for these patients were queried regarding the selection of discharge destination.



      Main Outcome Measures

      Comparison of actual discharge destination for stroke patients with the destinations recommended by their DPs and PTs.


      In total, 184 patients (43.1%) were discharged home, 146 (34.2%) to an inpatient rehabilitation facility, 94 (22.0%) to a skilled nursing facility, and 3 (0.7%) to a long-term acute care hospital. DPs and PTs agreed on the recommended discharge destination in 355 (83.1%) cases. The actual discharge destination matched the DP and PT recommended discharge destination in 92.5% of these cases. In 23 cases (6.5%), the patient was discharged to a less intensive setting than recommended by both respondents. In 4 cases (1.1%), the patient was discharged to a more intensive level of care. In 2 cases (0.6%), the patient was discharged to a long-term acute care hospital rather than an inpatient rehabilitation facility as recommended. Patient or family preference was cited by at least 1 respondent for the discrepancy in discharge destination for 13 patients (3.1%); insurance barriers were cited for 9 patients (2.3%).


      Most stroke survivors in the northeast United States are discharged to the recommended postacute care destination based on the consensus of DP and PT opinions. Further research is needed to guide postacute care service selection.


      List of abbreviations:

      DP (discharge planner), GWTG-Stroke (Get With The Guidelines-Stroke), ICH (intracerebral hemorrhage), IQR (interquartile range), IRF (inpatient rehabilitation facilities), LTACH (long-term acute care hospital), NECC (Northeast Cerebrovascular Consortium), NIHSS (National Institutes of Health Stroke Scale), PT (physical therapist), SNF (skilled nursing facilities)
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        • Benjamin E.J.
        • Virani S.S.
        • Callaway C.W.
        • et al.
        Heart disease and stroke statistics-2018 update: a report from the American Heart Association.
        Circulation. 2018; 137: e67-492
        • Winstein C.J.
        • Stein J.
        • Arena R.
        • et al.
        Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
        Stroke. 2016; 47: e98-169
        • Bravata D.M.
        • Ho S.Y.
        • Meehan T.P.
        • Brass L.M.
        • Concato J.
        Readmission and death after hospitalization for acute ischemic stroke: 5-year follow-up in the Medicare population.
        Stroke. 2007; 38: 1899-1904
        • Lakshminarayan K.
        • Schissel C.
        • Anderson D.C.
        • et al.
        Five-year rehospitalization outcomes in a cohort of patients with acute ischemic stroke: Medicare linkage study.
        Stroke. 2011; 42: 1556-1562
        • Appelros P.
        • Nydevik I.
        • Viitanen M.
        Poor outcome after first-ever stroke: predictors for death, dependency, and recurrent stroke within the first year.
        Stroke. 2003; 34: 122-126
        • Bates B.E.
        • Xie D.
        • Kwong P.L.
        • Kurichi J.E.
        • Ripley D.C.
        • Stineman M.G.
        One-year all-cause mortality after stroke: a prediction model.
        PM R. 2014; 6: 473-483
        • Wang H.
        • Sandel M.E.
        • Terdiman J.
        • et al.
        Post-acute care and ischemic stroke mortality: Findings from an integrated health care system in Northern California.
        PM R. 2011; 3: 686-694
        • Kane R.L.
        • Chen Q.
        • Finch M.
        • Blewett L.
        • Burns R.
        • Moskowitz M.
        Functional outcomes of posthospital care for stroke and hip fracture patients under Medicare.
        J Am Geriatr Soc. 1998; 46: 1525-1533
        • Chan L.
        • Sandel M.E.
        • Jette A.M.
        • et al.
        Does post-acute care site matter? A longitudinal study assessing functional recovery after a stroke.
        Arch Phys Med Rehabil. 2013; 94: 622-629
        • 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
        • Hong I.
        • Goodwin J.S.
        • Reistetter T.A.
        • Kuo Y.-F.
        • Mallinson T.
        • Karmarkar A.
        • Lin Y.-L.
        • Ottenbacher K.J.
        Comparison of functional status improvements among patients with stroke receiving postacute care in inpatient rehabilitation vs skilled nursing facilities.
        JAMA Netw Open. 2019; 2e1916646
        • Alcusky M.
        • Ulbricht C.M.
        • Lapane K.L.
        Postacute care setting, facility characteristics, and poststroke outcomes: a systematic review.
        Arch Phys Med Rehabil. 2018; 99: 1124-1140
        • Cormier D.J.
        • Frantz M.A.
        • Rand E.
        • Stein J.
        Physiatrist referral preferences for post acute stroke rehabilitation.
        Medicine (Baltimore). 2016; 95e4356
        • Stein J.
        • Prvu Bettger J.
        • Sicklick A.
        • Hedeman R.
        • Magdon-Ismail Z.
        • Schwamm L.H.
        Use of a standardized assessment to predict rehabilitation care after acute stroke.
        Arch Phys Med Rehabil. 2015; 96: 210-217
        • Pohl P.S.
        • Billinger S.A.
        • Lentz A.
        • Gajewski B.
        The role of patient demographics and clinical presentation in predicting discharge placement after inpatient stroke rehabilitation: analysis of a large, US data base.
        Disabil Rehabil. 2013; 35: 990-994
        • Hakkennes S.J.
        • Brock K.
        • Hill K.D.
        Selection for inpatient rehabilitation after acute stroke: a systematic review of the literature.
        Arch Phys Med Rehabil. 2011; 92: 2057-2070
        • Kumar A.
        • Adhikari D.
        • Karmarkar A.
        • et al.
        Variation in hospital-based rehabilitation services among patients with ischemic stroke in the United States.
        Phys Ther. 2019; 99: 494-506
        • Ilett P.A.
        • Brock K.A.
        • Graven C.J.
        • Cotton S.M.
        Selecting patients for rehabilitation after acute stroke: are there variations in practice?.
        Arch Phys Med Rehabil. 2010; 91: 788-793
        • Buntin M.B.
        • Garten A.D.
        • Paddock S.
        • Saliba D.
        • Totten M.
        • Escarce J.J.
        How much is post-acute care use affected by its availability?.
        Health Serv Res. 2005; 40: 413-434
        • Stillman G.
        • Granger C.
        • Niewczyk P.
        Projecting function of stroke patients in rehabilitation using the AlphaFIM instrument in acute care.
        PM R. 2009; 1: 234-239
        • Ween J.E.
        • Alexander M.P.
        • D’Esposito M.
        • Roberts M.
        Factors predictive of stroke outcome in a rehabilitation setting.
        Neurology. 1996; 47: 388-392
        • Inouye M.
        • Kishi K.
        • Ikeda Y.
        • et al.
        Prediction of functional outcome after stroke rehabilitation.
        Am J Phys Med Rehabil. 2000; 79: 513-518
        • Alexander M.P.
        Stroke rehabilitation outcome: a potential use of predictive variables to establish levels of care.
        Stroke. 1994; 25: 128-134
        • Magdon-Ismail Z.
        • Sicklick A.
        • Hedeman R.
        • Bettger J.P.
        • Stein J.
        Selection of post-acute stroke rehabilitation facilities: a survey of discharge planners from the Northeast Cerebrovascular Consortium (NECC) region.
        Medicine (Baltimore). 2016; 95e3206
        • Gropen T.
        • Magdon-Ismail Z.
        • Day D.
        • Melluzzo S.
        • Schwamm L.H.
        • NECC Advisory Group
        Regional implementation of the stroke systems of care model: recommendations of the Northeast Cerebrovascular Consortium.
        Stroke. 2009; 40: 1793-1802
        • Schwamm L.H.
        • Fonarow G.C.
        • Reeves M.J.
        • et al.
        Get With the Guidelines-Stroke is associated with sustained improvement in care for patients hospitalized with acute stroke or transient ischemic attack.
        Circulation. 2009; 119: 107-115
        • Xian Y.
        • Fonarow G.C.
        • Reeves M.J.
        • et al.
        Data quality in the American Heart Association Get With The Guidelines-Stroke (GWTG-Stroke): results from a national data validation audit.
        Am Heart J. 2012; 163: 392-398
      1. 2015 Definitive Healthcare Hospitals Database. Definitive Healthcare LLC. Available at: Accessed April 30, 2020.