Hello, everyone. Thank you for joining our course today, titled Envisioning a New Healthcare Delivery Model for Stroke, Improving Transition of Care, and Overall Outcomes. Please feel free to submit any questions using the chat box. We will have a question and answer section for the panelists at the end of the presentation. At this time, we ask that everyone mute their webcam and microphone for the best visual and audio experience. We want to thank the AAPMNR and the IT staff for doing a great job in organizing this event and allowing us to be together virtually today. My name is Dr. Talia Fleming. I am an associate professor at Rutgers Robert Wood Johnson Medical School and an assistant professor at Hackensack Meridian School of Medicine. I am also the medical director of the Stroke Recovery Program, Post-COVID Rehabilitation Program, and Aftercare Programs at JFK Johnson Rehabilitation Institute in Edison, New Jersey. Unfortunately, Dr. Sarah Cucurula wishes that she could be here with us today, but had a recent death in her family. She extends her gratitude for your attendance to this important lecture and knows that you will gain great insights from our powerhouse panel that we assembled to discuss this engaging topic. I'm so happy to announce our esteemed faculty joining us. They are distinguished and well accomplished in the field of PMNR, and we are so excited to hear their perspectives today. Dr. Booyang O. Park is the chief medical officer, senior vice president, and professor at Burke Rehabilitation Hospital through Albert Einstein College of Medicine in the Montefiore Health System. Dr. Preeti Raghavan is a Sikh Khalifa professor and director of the Center of Excellence for Treatment, Recovery, and Rehabilitation at the Sheikh Khalifa Stroke Institute. She is also the vice chair of research for the Department of Physical Medicine and Rehabilitation, the director of the Motor Recovery Research Lab, and an associate professor of Physical Medicine and Rehabilitation and Neurology at Johns Hopkins University School of Medicine. Dr. Carmen Tercik is a professor in the Department of Physical Medicine and Rehabilitation and the director of the Cardiovascular Rehabilitation Center through the Department of Cardiovascular Diseases at Mayo Clinic of Rochester. We will begin with Dr. O. Park and move through the subsequent presenters. Dr. O. Park, the floor is yours. Good afternoon. I would like to briefly talk about the impact of stroke on population health. This is my disclosure. There are three key discussion points in this presentation. These are significance of stroke in population health, overall stroke systems of care, and within that system, the optimum transition of care model for stroke rehabilitation. Worldwide, stroke is the second leading cause of death and the leading cause of severe disability. One in four people in the world will have stroke in their lifetime. In the United States, 800,000 strokes occurs every year. In terms of race, ethnicity, non-Hispanic black is two to three times higher risk than non-Hispanic white, and women are at higher risk lifetime compared to men. There has been tremendous progress in stroke care, including controlling risk factors such as hypertension, smoking cessation, and anticoagulation. Mortality associated with stroke was reduced by 70% over the past 50 years. In spite of this reduction in mortality, the absolute number of deaths and also life lost due to disability has been increasing. This is a graph from the study published in the Lancet Neurology in 2019 showing the global burden of a neurological disease. The x-axis represents age group, and the y-axis represents the DALY, that is, death and life years lost due to disability. Stroke is represented as a navy color as the dominating neurological disorder accounted for death and life years lost due to disability in others. How about the future burden of the stroke? In 2050, the incidence of the stroke is estimated to increase dramatically in the age group of 65 and older, with the largest increase is expected to be in the Hispanic male population. What about the disability and level of physical activities among stroke survivors? This graph shows that less than 10% of stroke survivors are physically active at two years post-stroke, which is reduced even further over time. This is clearly an area of opportunity for physiatrists to act on. Now, I would like to discuss the stroke systems of care in the next few slides. The most recent publication on this topic by the American Stroke Association emphasizes comprehensiveness of the systems care, and I want to highlight two areas in this guideline. One area is community education and primordial prevention of addressing social determinants and health behaviors, and this calls for action to develop support mechanisms to assist the community as a whole, and also patients and providers in the long-term adherence to primordial and primary prevention. Another important aspect of the guideline includes stroke rehabilitation and continuous quality improvement. This underscores the single dose of post-acute rehabilitation does not meet the needs of all stroke survivors. Standardized evaluation of patient outcomes across different rehab settings is emphasized, and in addition, functional assessment of stroke patients is recommended throughout lifetime instead of during or at the completion of a formal rehabilitation. Organizational structure of stroke rehabilitation in the United States is highly heterogeneous. The central driver of this structure, whether acute rehab, subacute rehab, and home care, is not necessarily a clinical one, unfortunately. Rather, the repeated changes to the federal reimbursement fee structures. The alarming fact is that the stroke patients who are not referred to rehab increased from 26% in 1996 to 42% in 2006. There are well-established guidelines for stroke rehabilitation. However, the challenge lies on the high-quality implementation of them. Successful incorporation of the stroke rehabilitation in the overall stroke system of care ultimately lies on what value proposition rehab offers and delivers in a reliable manner. The value proposition of stroke rehabilitation often includes reduction in readmission rates and length of stay in conjunction with financial well-being of the health care system. For example, 20% of stroke survivors are readmitted within 30 days, and 30% will be readmitted within 90 days. Most importantly, 50% of these readmissions are avoidable, and well-designed transition of care rehabilitation program, which you will hear from other speakers today, can make a great impact on these numbers. In summary, stroke remains to be the leading cause of a severe disability, in spite of improving mortality. Stroke systems of care must include rehabilitation, and for stroke rehabilitation to be successful, it should deliver the value proposition not only to the health care systems, but also to the payers. Thank you so much. And the next speaker will be Dr. Pradeep Raghavan. Hello, everyone. Thank you, Dr. Opak, for giving a great introduction. I'll be talking about examining the medical similarities between cardiac disease and stroke. These are my disclosures. What I would like to describe are the multiple risk factors that are common to both cardiac disease and stroke, and how can we learn from cardiac treatment models to advance stroke rehabilitation. As Dr. Muyon explained, stroke is extremely common and affects a large number of us. In 1993, Breslow and Breslow wrote an interesting article where they examined the epidemiology of cardiovascular health in a community in California, and found that there were seven critical elements, critical factors that contribute to cardiovascular health or risk. Blood pressure management, cholesterol, blood sugar, physical activity, nutrition, body weight, and smoking. And activity, physical activity, is particularly important because it influences all the others. In fact, the American Heart Association has adopted these. These are called Life's Simple Seven. I'd like to quote from Hippocrates from this very interesting article in the Journal of the American Heart Association. If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to help. So this is ages old, but in 2010, the American Heart Association finally adopted Life's Simple Seven and established criteria for prevention of heart disease and stroke. And basically, the physical activity guideline clearly states that the ideal amount of physical activity is at least 150 minutes per week of moderate activity, or greater than 75 minutes per week of vigorous activity, or greater than 150 minutes per week of moderate and vigorous activity. So basically, they established the minimum levels. And since then, the secondary stroke prevention checklists incorporate Life's Simple Seven. So besides anticoagulation for atrial fibrillation and all the other stroke-specific preventive methods, the idea is to incorporate all of these seven elements as well. As far as physical activity is concerned, in 2019, the guideline stated that physical activity improves stroke risk factors and may reduce stroke risk itself. But what it recommended was that for patients who are capable of engaging in physical activity, they should have at least three to four sessions per week of 40 minutes of moderate to vigorous intensity aerobic physical exercise. So it was for patients who are capable. So now if you look at 2021, the language has actually changed. It says it clearly reduces stroke risk, it positively impacts stroke risk factors, and they should engage in a minimum amount. But it also states that for patients with deficits that impair their ability to exercise, you need a supervised exercise program. So the recommendation for physical activity is currently, though, still a 2A. That means there is a moderate... The benefit is greater than risk, but there is moderate evidence, and it is really based on expert opinion only, right? So we still have a ways to go. The biggest challenge that these 2021 guidelines for prevention of stroke and patients with stroke suggest is that we need to do more to change patient behavior, right? It's not enough to give simple advice. We actually have to create the programs. So how do we create the programs? How do we institute a model of behavior change? The 5A model suggests that you need to assess, advise, agree, assist, and arrange for behavior change to occur. Assessing physical activity means that physicians need to counsel patients because they are 42% more likely to be active after receiving physician counseling. But only one third of clinicians actually do so right now. And assessment of physical activity should be considered a vital sign. At the very least, you need to ask, how many days per week do you engage in moderate or greater physical activity, and how many minutes do you engage in it? We need to advise the patient on the importance of regular physical activity, especially in those who are just beginning to engage in physical activity because even they can have the greatest benefit. With the patients, we need to agree on physical activity goals. The goals need to be smart. So they have to be specific, measurable, attainable, relevant, and timely. And we need to provide an exercise prescription as per the guidelines of the American Association of Sports Medicine. And finally, we have to understand the potential barriers and challenges so that we can assist them. And then we need to arrange to facilitate physical activity. How about a cardiac rehabilitation program post-stroke? Is it possible? In fact, what I'd like to leave you with is a message that, why is it not possible? It should be a part of stroke rehabilitation. In fact, out of the 13 core performance measures that have just recently been identified for implementation of stroke rehabilitation, the 13th measure clearly states that patients with stroke should be provided with an individually tailored exercise and fitness program. So, in other words, we have no excuses. We, as physiatrists and stroke providers, are on the line to provide an individually tailored exercise and fitness program as part of stroke rehabilitation. Thank you for your attention, and I'll now pass it on to Dr. Teresik. Thank you for this opportunity, and thank you, Pradeep, for presenting, now giving the introduction to my presentation. So, what I would like to present now is to discuss exploring the importance of cardiac rehabilitation. The previous presenter talked about what is the impact of stroke in our patients and how cardiac rehabilitation and the similarities that happen with stroke and how it makes sense, why we don't consider a program such as cardiac rehabilitation for stroke care. Now, let's talk about what brings cardiac rehabilitation, why this could be a good example to use in other modern diseases such as a stroke. Nothing to disclose. So, what is cardiac rehabilitation? So, cardiac rehabilitation is a comprehensive and multidisciplinary and systematic, this is very important, systematic approach that is focusing on education, individualized exercise training, nutrition, counseling, therapy, risk factor and modification, medical conditions, psychosocial health, optimization of functional status, monitor progress, problem coordination of heart related care, and support of compliance and adherence. There are multiple, multiple research and publications showing the importance of cardiac rehabilitation for the care of cardiac patients, and many of them showing the importance of programs such as cardiac rehab and the importance of the dose response. So, they must visit a session that the individual has during the cardiac rehabilitation, having shown that the outcome in terms of the incidence, either mortality or re-hospitalization, decreased significantly as the number of sessions increased, as you can see over here. And what are the mechanisms, what are these benefits of cardiac rehabilitation, why this huge impact? And it's because, of course, the exercise, the effect of exercise, physiological effect of exercise, but also of the education component of this program, the nutrition, so how we educate the patient about healthy nutritional habits. Control, also control of cardiovascular risk factor. We assess during this program comorbid condition and control them, psychosocial support, we identify and treat symptoms as they present, and also the importance for the patient to be consistent with the medication. And here I'm going to bring you some example of the impact of cardiac rehabilitation program, all of these parameters. For example, cholesterol, lipid profile. It has been shown that if you participate, if a patient participate in a cardiac rehabilitation program, there is a significant improvement of the lipid profile. And this improvement is even greater in patient with abnormal values to begin with. Cardiovascular risk factors. So the participation in cardiac rehab program make the patient to improve the insulin resistance. There is a decrease of blood pressure, specific in hypertensive patient, but also in normal individuals. Improve the metabolic syndrome, we reduce the percent of fat. Also, there is an important of a positive effect of cardiac rehabilitation in adverse psychosocial stress parameters, specifically depression, anxiety, hostility. We see that patient that participate in cardiac rehabilitation, they are a significant decrease of this stress, psychological stress parameter, and this is independent of age. So young and elderly, they have the same positive effect. And not only that decrease these symptoms of controlling, but also decrease the mortality associated with the depression in these patients. You can see this in this report. 70% of reduction of mortalities in patient with depression compared with the control group, which is the people that do not participate in the program. Smoking cessation. We all know how important it is and how impact smoke have on the health. So the stronger predictor of smoking cessation at six months was participation in cardiac rehabilitation program. So this highlight how, I mean, the impact of this program in smoking cessation. Also medication adherence. This is a nice study showing us after a myocardic infarction, patient have 74% receiving statin, but only 44% after three years. The same thing with beta-blocker and NKNAC inhibitor. So there is a significant drop of the adherence to the medication. However, in patient that participates in the cardiac rehab program, this is data from our program. As you can see, three years after, there is a significant number of them still are taking their medication compared with, as I showed you before, patient that do not participate in the program. So that is very important as well. And this is, for me, one of the most appealing data showing how there is so much decrease and impact on readmission after myocardic infarction and in all cause of admission, not only cardiovascular, but all caused by 25% patient who participate in cardiac rehabilitation program. And also, not only in readmission, but mortality also. There is a huge impact in mortality after myocardial infarction, as you can see here, when you compare the patient that do not participate compared with patient who participate in the program. And it's not only myocardial infarction, but also in other situation as well. For example, after PCI, there is a study that show there is a decrease of 45% of all-cause mortality in cardiac rehabilitation participant. And after bypass surgery, the same thing, 46%. So there is no other intervention that you can see a few other intervention that exist that can produce this huge impact in mortality as cardiac rehabilitation. And quality of life. I mean, we're talking about parameters like mortality, morbidity, but quality of life also is positive effect on individual participating in cardiac rehab program. So those are the benefits. I mean, we can spend more time just discussing the benefits, but I want to highlight some of the most important. And as you can see, control of risk factor is key. And what are these risk factor in cardiac disease? Smoking, high cholesterol, blood pressure, diabetes, overweight, nutrition, diet habits, sedentary. And what are the risk factor for stroke? It's the same, similar. Therefore, we have overwhelming evidence that support the role of cardiac rehabilitation program in the prevention of cardiac and vascular disease. Therefore, adopting this principle of cardiac rehabilitation for other vascular disease such as stroke, for us is the next logical step in improving patient outcome. So thank you very much. And I will now allow Dr. Talia Fleming to take the podium. Thank you, Dr. Tercik. So for this portion of our course, I will present new data from our clinical research trials, investigating and analyzing the effects of a comprehensive stroke recovery program on all cause mortality, cardiovascular performance, function and readmissions. For those of you who may have missed our opening announcement, Dr. Cucurullo regrets not being able to make our presentation today, being that she had a recent death in her family. We both extend our gratitude for your attendance, and I'm excited to share some of our recent published data regarding our innovative clinical research. Our disclosures include several grants awarded to our institution for the research point portion of the JFK Johnson Stroke Heart Trials. By the end of this presentation, we will review that stroke care and recovery is a national problem, which is projected to get worse. We will understand that the stroke recovery program takes a proven model used in cardiac rehabilitation and improves the healthcare delivery model for stroke survivors. We will also review the outcomes of the stroke recovery program, showing that it benefits function, mortality, rehospitalization and cost, as well as address that post-stroke care deserves the same healthcare delivery options that we know work extremely well for the cardiac rehab population. In 2016, the American Heart Association and American Stroke Association published guidelines for adult stroke rehabilitation and recovery, suggesting that stroke survivors who qualify for inpatient rehabilitation facility or IRF services should receive inpatient rehabilitation and preference to skilled nursing facility-based care. This declaration was in response to finding that IRF patients have higher rates of return to community living and greater functional recovery compared to skilled nursing facility care, which results in higher hospitalization rates and substantially poorer survival. Research has also shown that only 30% of stroke survivors receive outpatient rehabilitation, which is lower than what would be expected if clinical practice guideline recommendations for stroke patients had been followed. For patients under Medicare, which is the largest insurance provider for those over age 65, there is a limit or a threshold to the amount of financial support given annually for therapy services. For recent years, it's been just over $2,000 for physical therapy and speech and language pathology services compared to just over $2,000 for occupational therapy services. But we also know that cardiac rehabilitation and pulmonary rehabilitation have a separate financial carve-out outside of the basic Medicare therapy financial limitations. Thereby, patients doing cardiac rehab have access to an additional 36 sessions of specialized therapy services. The following are the diagnosis that are included as candidates for cardiac rehabilitation under current Medicare guidelines, including coronary artery disease, coronary angioplasty or stenting, cardiac surgery, and congestive heart failure under specific criteria. This short video was created by two cardiologists from the Mayo Clinic in Rochester, Minnesota, and supported by evidence-based medicine. They found that cardiac rehab after percutaneous coronary angioplasty was associated with an impressive 45 to 47% reduction in five-year all-cause mortality compared to non-participation. Dr. Tercik described some of the goals of cardiac rehab rehabilitation. And number one is to maintain or improve function for cardiovascular fitness. Number two is to reduce the risk of future cardiovascular events, also improving modifiable risk factors and improving adherence to medication regimens. We talked about the improvement in the quality of life as well as adopting lifelong healthy behaviors. And overall, there's a decrease in mortality at five years post-participation. But patients recovering from stroke must use limited Medicare funding within the Medicare therapy threshold for outpatient therapies. And this puts our patients with stroke at a tremendous disadvantage. They have limited access to therapy during their stroke rehabilitation. And if they end up having a second medical event within the same year requiring therapy, those therapy needs may not have full financial insurance coverage. Patients with stroke often share many of the same risk factors as cardiac rehab patients, such as high blood pressure, diabetes, or hyperlipidemia. But the difference is that they will often have more involved functional deficits, including dysphagia, aphasia, hemiplegia, cognitive deficits, as well as spasticity. So we designed our stroke recovery program to address these issues and create a mini cardiac rehab experience for stroke survivors. The foundation of the program starts with our outpatient physician visit with one of our stroke physiatrists. At that appointment, physical therapy, occupational therapy, and speech therapy are prescribed based on the patient's need. At that time, patients are also enrolled in our innovative cardiovascular group, which is a modified cardiac rehabilitation protocol and meets three times per week to focus on cardiovascular conditioning. When indicated, referrals to nutritional support, rehabilitation psychology, neuropsychology, and even driver training is provided. Also at the physician visit, education is given regarding nutrition, smoking cessation, knowing the warning signs for stroke, and also a mood assessment. A question we often received as we were developing the program was, well, how is it that stroke survivors can do exercise? Oftentimes neurologists or primary care doctors were somewhat confused with our attempt to create this cardiac rehab program for our stroke patients. In our experience, we devised an innovative approach addressing the most common challenges that present during stroke rehabilitation, including weakness, cognitive deficits, poor safety awareness, post-stroke fatigue, cardiovascular instability, as well as other comorbid conditions. In the photo, you can see that when needed, we use additional hand mitts to support a weak upper extremity, as well as a thigh support to support a weaker lower extremity. We solve some of these challenges by developing an interval cardiovascular training program on a recumbent cross-training bicycle. A cardiac clearance form is signed prior to discharge from the inpatient rehabilitation hospital stay. The modified cardiac rehab program is administered in a group setting with a low to moderate intensity, and fitness education is provided during each of the 36 sessions, very similar to what a traditional cardiac rehabilitation program offers. So after creating the stroke recovery program with modified cardiac rehab, we designed a clinical research trial to collect data on the effectiveness of the program. From an overall medical perspective, we wanted to determine if the stroke recovery program could reduce hospital readmission, recurrent stroke, and overall mortality. From a functional perspective, we wanted to determine if the stroke recovery program could improve function measured by the AMPAC, which stands for the Activity Measure for Post-Acute Care, and also improve cardiovascular conditioning. Our overall goal was to accrue data, to publish and to prove to Medicare that patients with stroke deserve the same comprehensive rehab program that patients with cardiac disease receive to achieve maximum functional results, which is funded outside of the Medicare therapy limitations. So our initial research design was twofold, designed to follow the trajectory of patients recovering from acute stroke after discharge from an IRF, inpatient rehab facility. Stroke recovery program participants were defined as those who had three components of our protected program, almost imagine like a step-down unit, which is for an outpatient program in the outpatient setting. Stroke recovery program participants were required to have all of the following, outpatient physiatry physician visits, outpatient therapy, and modified cardiac rehabilitation at JFK Johnson Rehabilitation Institute. Non-participants were those who were discharged from the IRF, but did not get physician visits, therapy, nor modified cardiac rehab at JFK Johnson Rehabilitation Institute. Now, these patients may have had some physician and therapy follow-up, but it was outside of the structured stroke recovery program supported framework. And we designed it this way intentionally to mimic what most stroke survivors will experience as a standard of care across the country. Some may have access to some therapy, some may not, but it's not that structured specific program. A prospective feasibility study of the stroke recovery program participants assessed the implementation of the enhanced stroke recovery program, which again included those three components, physician visits, outpatient therapy, and modified cardiac rehab at JFK Johnson Rehab Institute. The stroke recovery program evaluated the following outcome measures. We looked at safety, mortality, cardiovascular performance, functional performance, as well as the patient and staff perspective. A non-randomized matched subgroup analysis compared stroke recovery program participants to matched pairs of non-participants. And the subjects were matched on gender, race, type of stroke, and partially on age, baseline functional scores, medical complexity. Both groups were compared based on mortality and pre and post function. This descriptive table shows the extensive matching criteria used to compare the stroke recovery program participants with the non-participants prior to the data analysis. As you can see, this is an extensive list of variables that we use for matching. We really wanted to take into account the demographic information, stroke specific details, stroke complications, as well as other comorbid medical conditions. So after matching, the results were analyzed. The graph on the right shows the feasibility study results of the stroke recovery program participants with the X-axis showing progression over time, starting at baseline, and intervals of each of nine sessions. The Y-axis shows the average met minutes achieved by that session number. The data showed that the patient safety during the interval cardiovascular training with a specific protocol with progression. So we were able to prove that the interval training was safe. The data also showed improvement was seen in exercise duration over time, meaning participants were able to exercise for a longer period of time. Improvement in exercise capacity, which was measured in met minutes, was seen as early as nine sessions and continued throughout session 36 with statistical as well as clinical significance. This graph shows the same results expressed in percentage improvement at each session compared to baseline. By 36 sessions, the average percent improvement from baseline was 103%, showing statistical and clinical significance. With regards to functional improvement, we looked at specific functional improvement using the activity measure for post-acute care or ANPAC. The ANPAC measures several domains. First is basic mobility measured in physical therapy skills. Daily activity is a measure of occupational therapy skills, and applied cognitive is a measure of speech therapy skills. We chose the ANPAC for several reasons. We wanted a functional outcome score that can be measured across post-acute care settings from hospital to IRF to skilled nursing facility to home care and then finally to an outpatient ambulatory care setting. Another advantage is the breadth of the ANPAC consists of a comprehensive list of over 269 functional activities covering severely impaired function all the way up to very high level functioning. In all three domains, for the physical therapy or basic mobility score, occupational therapy or their daily activity score, as well as speech therapy, which is more of the applied cognitive score. After scoring, a numeric measure of function is provided that can be tracked over time. That was another advantage knowing that we're gonna be following the patient through their whole post-acute care time. And the ANPAC tool is also recognized by Medicare as a valid functional tool to measure functional health status change. This graph shows the ANPAC basic mobility score over time. The X-axis is time measured in days after stroke onset, starting from IRF hospital admission to 120 days after stroke onset. The Y-axis is the measure of the ANPAC score for that particular domain. The line with the triangle markers shows the scores for the non-participants, while the line with the star marker shows the score for the SRP participants. Now, most patients who have a stroke will spend about three to seven days in the acute care hospital, then an additional two to three weeks at an IRF if they are accepted at that setting. As a result, most patients are discharged to an outpatient setting around day 30 after stroke, which is when the outpatient stroke recovery program gets integrated as a novel option compared to traditional outpatient stroke care. When looking at the graph from hospital admission to hospital discharge, both scores for non-participants and SRP participants are about the same, showing similarities between groups. At the 30-day time point, the lines diverge. By the 120-day time point, the non-participants show some improvement. However, the SRP participants show improvement that is statistically and clinically significant. This graph shows the ANPAC daily activity score over time. From hospital admission to hospital discharge, again, we see that both scores for non-participants and SRP participants are about the same, showing similarities between the groups. And at the 30-day time point, the lines diverge. By the 120-day time point, the non-participants show some improvement. However, the SRP participants show improvement that is statistically and clinically significant. This last graph shows the ANPAC applied cognitive score over time, and we see the very similar trend. From hospital admission to hospital discharge, both scores for non-participants and SRP participants are about the same, showing the similarities between both groups. And after the 30-day time point, the lines diverge. By the 120-day time point, the non-participants show some improvement. However, the SRP participants show improvement that, again, is statistically and clinically significant. With respect to mortality, the results were even more impressive. After matching, one death was reported in the SRP participant group, which was about 1.3%, compared to 10 deaths in the non-participant group, which was about 15.2%. Kaplan-Meier curves for each of the groups in the matched cohort are shown. And when we fit a Cox proportional hazards model, it suggested that non-participants have about a 9.09 times higher hazard of mortality, which is statistically significant. The one-year death rate of the general stroke population in get-with-the-guidelines stroke hospitals was published at about 31% nationally. In comparison, patients who completed the stroke recovery program had only a one-year death rate of 1.47%. So, this manuscript summarizing this data was published in the November 2019 issue of the American Journal of Physical Medicine and Rehabilitation. With the conclusion that stroke survivors receiving a stroke recovery program integrating modified cardiac rehabilitation may potentially benefit from reductions in all-cause mortality and improvements in cardiovascular performance and function. So, after publishing our data, CMS or Medicare, they asked us to speak with them about our research, and while meeting with them at the Center for Medicare and Medicaid Innovation Headquarters in Baltimore, Maryland, they were very excited to hear our data and asked us to gather more information. They wanted to know more about the financial aspects of running the program, and this is part of the reason why. The cost of stroke care in the United States is expected to soar, with estimates published in this article from the Stroke Journal projected as over $240 billion by the year 2030. The stroke recovery program improves the healthcare delivery model, recommending that patients be transferred from the acute care hospital, transferred to an inpatient rehabilitation facility, as currently 22% of Medicare patients currently do, and then discharged home to an outpatient stroke recovery program. Our next step was to analyze the financial impact of the stroke recovery program. We wanted to do that based on some of the feedback we got from CMS. So, we compared the stroke recovery program participants to non-participants using the same matching criteria as our first study. So, these are going to be the results for our next study. Our descriptive table, again, shows the extensive matching to compare both groups prior to analysis. And we found that all-cause one-year hospital readmission rates were statistically significant between groups, with the non-participants showing a one-year hospital readmission rate of 67%, and the stroke recovery program participants showing a rate of 45%. And altogether, that's a difference of about 22% between the groups. This table compares the cost of standard of care, access to therapy services, and hospital readmission, compared to the cost of stroke recovery program services and hospital readmission. We asked the question, if the stroke recovery program was offered to all 795,000 persons diagnosed with stroke each year, what could the potential cost savings be related to hospital readmission? With the stroke recovery program reducing hospital readmissions by 22%, and the average cost of all-cause hospital readmissions nationally at about $14,400, the potential savings attributed to hospital readmission costs by using the stroke recovery program could be approximately about $1.12 billion. Now, we know that practically, not everyone may need or may be able to attend an outpatient program like the stroke recovery program. So next, we wanted to look specifically at the medically complex population who may be best suited to benefit from a protected step down outpatient program after hospital admission. Knowing that 22% of Medicare patients go to an IRF, we asked the question, if the stroke recovery program was offered to all IRF stroke discharges, what could the potential cost savings be related to hospital readmission? This table compares the cost of standard of care, access to therapy services and hospital readmission, compared to the cost of SRP services and hospital readmission specifically after IRF discharge. And again, with the stroke recovery program reducing hospital readmissions by 22%, and the average cost of hospital readmission nationally at $14,400, we found that it could be approximately $200 million in savings. When comparing the cost of conventional care therapy to the cost of delivering the SRP, we estimate a cost of about $4,160 for conventional care compared to $5,954 for the stroke recovery program, the difference of which is significantly less than the cost of even one hospital readmission. So this manuscript summarized this data was published in February 2021 issue of the American Journal of PM&R with a conclusion that acute care hospital readmissions were reduced in stroke survivors who participated in the stroke recovery program. Besides hospital readmission, there are other cost savings that can be found with the improvement in function. Patients with stroke are the largest patient population receiving long-term care. And Medicare costs an average of $33,000 for stroke patients discharged to a nursing home, and only $13,000 for those who are cared for at home. About one-fourth of Medicare beneficiaries discharged from the hospital to a skilled nursing facility were readmitted back into the hospital within 30 days. And this cost Medicare over $4 billion, and that was back in 2006. So if the stroke recovery program can improve function, this would reduce the level of utilization of Medicare dollars, not only through admissions to nursing homes and hospital readmissions, but also less utilization of Medicare resources. We've been fortunate enough to be able to present our data at multiple national conferences, including the AAPM&R, the AAP, the ACRM, as well as AMPRA. And we were fortunate enough to present at the American Heart Association Scientific Sessions in Anaheim, California, which received national attention and support. We were also honored to present our research internationally in Japan at the International Society of Physical Medicine and Rehabilitation as part of our panel discussing innovations of care and rehabilitation of medically complex patients. So this brings us back to our overarching goal. Stroke survivors deserve better. So we're seeking to accrue data and publish and prove to Medicare that patients with stroke deserve the same comprehensive program outside of the Medicare therapy limitations. Before February 2014, these were the medical diagnoses approved for cardiac rehabilitation. And after February 2014, coverage for cardiac rehab services were extended to include stable chronic heart failure, which meets specific clinical criteria. After publishing evidence-based medicine, CMS determined that the evidence is sufficient to expand coverage for cardiac rehabilitation services to beneficiaries with stable chronic heart failure. With the expansion of these accepted diagnoses, cardiac rehab was extended as to a whole new group of people, which could literally change the trajectory of their life. Future steps for the Stroke Recovery Program will follow in these footsteps to add stroke as a covered diagnosis for cardiac rehabilitation services. And this collaborative presentation shows the importance of working together to achieve these goals at the national level to transform healthcare for stroke survivors. Thank you very much for your attention. We will now transition to the question and answer portion of our presentation. And I just wanted to start off by asking all of our other distinguished faculty that are joining us today, why is now such an important time to reimagine post-stroke care? I'm happy to jump in. So, as I presented earlier, people are recognizing the importance of behavior change. It's always been there, but it's now recognized much more widely. And therefore, you know, we no longer have any excuses. I think transitions of care, the importance of transitions of care for a chronic population like individuals with stroke has been well-established. We know that the costs are increasing, and we have to do what it takes. And therefore, with your data, Dr. Fleming, the time is really now. And I think, as we discussed today, there is overwhelming evidence that controlling risk factor for vascular disease, and stroke is a vascular disease, the patient outcome is impacted enormously. Medicare rehabilitation shows how the mortality and morbidity and re-hospitalization is decreasing by just getting into a structurally program of controlling risk factor. So, in my mind, there is no brainer. The next step will be to advocate, all of us together, to CMS and advocate for having a stroke as one of the indications for programs such as cardiac rehab. It took many years for peripheral vascular disease to be approved, but I think it will take less for a stroke with this overwhelming evidence. Thank you both. Yes, this is definitely a group effort, and we appreciate you and your institutions and, you know, being able to take the next step. I'm looking at the chat. There's definitely a few questions coming through, so thank you all for being so engaged. Several questions came out about the race and social determinants of health and ethnicity and how does that incorporate into everything. All excellent questions, and we are in the process of taking a look at that data and figuring out what that actually means. As a clinician running the stroke recovery program, seeing patients every single day, one of the advantages of having the physician visit is that on a one-to-one basis, I can help to intervene with patients to help them overcome those barriers. For some people, it's their finances. For other people, it's transportation. For other people, it's medical complexity. So, one of the things I really like about the program is being able to interface with patients one-on-one, identifying what those barriers are, and helping them overcome those barriers. I oftentimes say every stroke is different, every person with stroke is different, every situation is different. And honestly, over time, their needs change. At the 30-day hospital, I'm sorry, at a 30-day appointment after discharge from the hospitalization, oftentimes patients get these big packets of discharge papers and they just get home and they don't even know what that first step is. So, they come to our appointment and we tell them what to do specifically. Compared to three months down the line, if they still can't go back to work, that appointment is very different. Oftentimes, we're talking about disability paperwork and what does this mean in terms of your family and the caregiver support. And so, being able to customize everyone's recovery process is definitely an honor. And it's one of those spaces that physiatry can definitely step into as we move future into post-hospital and post-inpatient care. Another question, go ahead. I would like to mention in that regard that there is a lot of evidence in the literature that there is a lot of inequity in care of patients, specifically cardiovascular patients. So, the referral, starting with referral, full referral to the programs and then the admission, then the patient is able to stay into the program because of the multiple factors that you mentioned. So, we can use also that experience to overcome those barriers when we, because we will do that when we put a stroke and recovery program in action. I just want to mention that this has social determinants of health. It's really 80-90% of the patient's health, right? So, nowadays, the trend for the healthcare system level is collaborating with other industries, such as, you know, the sugary drink and something a little more comprehensive approach. And that has been emphasized in many of the guidelines. So, it's really an amazing time how much we can collaborate, think out of the box. And for example, you know, I work in New York area where the Bronx, the lowest poorest county in the nation. And there is a movement of eliminating sugary drinks from healthcare systems and any companies. So, those are kind of more fundamental approach about the, any cardiovascular risk of control. So, I just want to mention collaboration with other industries. And also, I will add that to add the technology, we can, should take advantage of technology to deliver this care for individuals that cannot travel. You know, Talia talked about transportation. This is one of the main barriers. So, how we can, again, engage industry to support the delivery of care in telemedicine, telecare. Absolutely. And that leads us into some of the other questions that are coming through on the chat box. Some questions about, you know, does insurance cover this? And is there an opportunity to take a look at, you know, nutritional support? And how are we educating patients on that? The great thing about this is that this is a framework. So, the patients are coming in, getting them to come in is really one of the first steps. From that particular point, we, the sky is the limit for the ways that we can customize rehabilitation or customize recovery for our patients. So, definitely looking as more specifically into nutrition is an important goal. The cardiac rehab portion will provide some of that exercise framework. And honestly, when patients are done at that 36 sessions, we have them transition to a healthy lifestyle or to our fitness center or to a fitness center closer to their home. But they're much more willing to take that step because they have more confidence in their physical capabilities. In terms of this specific research trial, we were very fortunate that we got several grants to kind of keep us going throughout the process. But our administration was very supportive of this. So, the therapy that the patients got was from their basic insurance benefit. And the administration, as well as our grants, covered the portions of the cardiovascular group. So, that's why it was so important. We didn't want to make, we didn't want to take any more money out of the patient's Medicare therapy threshold. But that leads to why this is so important for us to have a separate carve out for patients. Because they're not trying to game the system. They're just trying to get better. And so, it makes sense for us to create a specific program for them. So, Talia, I don't know if you want to talk about the strategy to make CMS to approve that so our patient will benefit. Right. So, we do know, and I know we're leading up towards the end of this session. Thank you all for your patience. We do know that Medicare responds to evidence-based medicine. And we've proven and we will continue to improve the fact that it helps them get better. They also wanted the portion of the cost savings. So, our future direction will be to marry those two areas. And really, with between advocacy and then also kind of grassroots efforts, we hope to present a strong case with them. Again, I mentioned the CMMI, the Medicare Innovation Center. They were very excited about this particular project. So, we have their ear. Next step is to get the data and push this forward. So, I think we've reached the end of our time together. Thank you all again for joining us. And enjoy the rest of your conference. I will continue to take a look at the questions in the chat box. I know there was one about the data. There's the two published articles in the American Journal of PM&R, Cucurulo 2019 and 2021. Those are the specific information if you want more information from there. Okay. Thank you. Enjoy your conference. Have a great day.

stroke recovery program

healthcare delivery

stroke survivors

population health

stroke care

clinical research trials

cardiac rehabilitation

comprehensive approach

telemedicine