Supporting True Functional and Participation Change Post-Stroke
By: Lauren Sheehan, OTD, OTR/L
With decreasing length-of-stays and disjointed outpatient systems of care, additional support is needed to provide stroke survivors and their care partners with the education, resources, and guidance to navigate the healthcare landscape. Programs designed for stroke survivors need to anticipate and adapt to those individual needs accordingly.
About the Modified Rankin Scale
The modified Rankin Scale (mRS) is used as a global measure of function after stroke. Its limitations include a need for granularity in identifying factors that contribute to improvements. Much of the use of the mRS in the literature has focused on interventional efforts to reduce damage in the acute phase of stroke. Subacute and chronic outcomes relate more to the management of comorbidities, social determinants of health, and receiving necessary follow-up care to monitor and mitigate risk factors.
The simplified modified version of the Rankin Scale Questionnaire was published in 2011 and verified as having excellent reliability both in person and by telephone. It can be administered in less than 1.5 minutes by a wide variety of raters and correlates with quality of life². This view of the mRS has been supplemented with questions that can be used to understand additional stroke survivor needs to support gains on the mRS. 
Addressing Barriers to Recovery
Post-stroke recovery requires support for a complex combination of physical, cognitive, and emotional impairments experienced by survivors. The mRS does not capture mental health needs or social needs supporting positive outcomes after stroke.
The mRS is a limited assessment of function in comparison to the complexity of post-stroke sequelae. Stroke programs attempting to meet post-acute survivor needs and improve program outcomes would benefit from incorporating Patient Reported Outcome Measures (PROMs) in post-discharge follow-up.
Based on the variety of post-stroke needs, supplemental PROMs are utilized both to understand the needs of survivors and care partners as well as to measure outcomes related to function, social needs, stroke impact, lifestyle changes, health-related quality of life, and other unmet needs.
Using a survivor-centric and impairment informed approach, clinical navigators tailored their interventions to the survivor and care partners’ needs based on social determinants of health (SDOH), impairments, and subsequent stroke risk.
A lens of self-determination theory was utilized to encourage participants to “Take Charge” of their life and health after stroke. The “Take Charge” intervention is utilized between weeks 6-8 to encourage a sense of purpose, autonomy, mastery and connectedness with others. In several randomized controlled trials, recipients of “Take Charge” have demonstrated decreased dependent disability (mRS 3 to 5) at 12 months.
The number of social needs (SDOH) identified for a survivor appeared to be correlated with the need for a greater number of navigator touch points, however, the complexity of social needs was not considered in the overall count of social determinants of health. Survivors were followed for an average of 10 touch points, or an average of 5.8 hours over 12 weeks, based on need².
There appear to be correlations between the engagement of survivors, defined as the number of touch points with a clinical navigator, and increased social needs, a greater number of stroke related impairments and care partner participation. In addition, engagement of survivors appears to also be correlated with outcomes such as 90-day readmissions, with the participants with the lowest engagement experiencing the highest readmission rates¹.
Outcomes
Clinician-assessed mRS scores were captured for 95% of participants at 90 days following hospital discharge². This high rate of success was likely due to ongoing relationship and trust building between survivors and their clinical navigator. Significant functional improvement was seen, with 81% achieving mRS scores of 0-2 at 90 days, compared to 57% of participants at mRS 0-2 at the time of enrollment².
To continue exploring Kandu Health's program data, check out Kandu Health's clinical abstract posters from the 2023 Association of Neurovascular Clinicians annual meeting by Lauren Sheehan, including the best-in-show award winning poster, "Complex Needs & Dynamic Solutions – Metrics that Yield Outcomes in a Post-Acute Stroke Navigation Program".
The research presented by Lauren Sheehan is based on Kandu Program data up to November 2023 (on file at Kandu Health).
Lauren Sheehan, OTD, OTR/L is the Senior Director of Clinical Services at Kandu Health, based in Campbell, CA
