Which Road to Recovery?: Factors Influencing Postacute Stroke Discharge Destinations: A Delphi Study

Cite: Stroke. 53. 10.1161/STROKEAHA.121.034815.

Background and Purpose
The criteria for determining the level of postacute care for patients with stroke are variable and inconsistent. The purpose of this study was to identify key factors influencing the selection of postacute level of care for these patients.

We used a collaborative 4-round Delphi process to achieve a refined list of factors influencing postacute level of care selection. Our Delphi panel of experts consisted of 32 panelists including physicians, physical therapists, occupational therapists, speech-language pathologists, nurses, stroke survivors, administrators, policy experts, and individuals associated with third-party insurance companies.

In round 1, 207 factors were proposed, with subsequent discussion resulting in consolidation into 15 factors for consideration. In round 2, 15 factors were ranked with consensus on 10 factors; in round 3,10 factors were ranked with consensus on 9 factors. In round 4, the final round, 9 factors were rated with Likert scores ranging from 5 (most important) to 1(not important). The percentage of panelists who provided a rating of 4 or above were as follows: likelihood to benefit from an active rehabilitation program (97%), need for clinicians with specialized rehabilitation skills (94%), need for active and ongoing medical management and monitoring (84%), ability to tolerate an active rehabilitation program (74%), need for caregiver training to return to the community (48%), family/caregiver support (39%), likelihood to return to community/home (39%), ability to return to physical home environment (32%), and premorbid dementia (16%).

This study provides an expert, consensus-based set of key factors to be considered when determining where stroke patients are discharged for postacute care. These factors may be useful in developing a decision support tool for use in clinical settings.


Are Stroke Survivors Discharged to the Recommended Post-Acute Setting? Archives of Physical Medicine and Rehabilitation.

Cite: 101. 10.1016/j.apmr.2020.03.006.

Objective: Examine the processes and barriers involved in providing post-discharge stroke care.


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


Twenty-three hospitals in the northeastern United States.


After exclusions, data on 427 patients hospitalized with a primary diagnosis of stroke between 05/2015 to 11/2016 were examined. 45% of patients were female; median age was 71. DPs/PTs caring for these patients were queried regarding the selection of discharge destination.



Main Outcome Measures

Comparison of actual discharge destination for stroke patients to the destination(s) recommended by their DPs and PTs.


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 recommended discharge destination in 355 (83.1%) cases; of these, the actual discharge destination matched the DP/PT recommended discharge destination in 92.5%. 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 (when inpatient rehabilitation facility was recommended). Patient/family preference was cited by at least one respondent for discrepancy in discharge destination for 13 patients (3.1% of 355 cases); insurance barriers were cited for 9 patients (2.3% of 355 cases).


Most stroke survivors in the Northeast are discharged to the recommended post-acute care destination based on the consensus of DP and PT opinions. Further research is needed to guide post-acute care service selection.