Recommendations for the Establishment of Stroke Systems of Care: A 2019 Update: A Policy Statement From the American Stroke Association

Essential for developing a cohesive, aligned regional or state stroke system of care is identifying and engaging all potential stakeholders at the outset. Early incorporation of all stakeholders ensures that the concerns of various groups are considered and addressed before the program is too far along. Often, the absence of a critical stakeholder is recognized during the process, and the concerns of that stakeholder create significant obstacles to moving forward. Fortunately, developing regional stroke systems of care has predicates for these efforts. Similar systems of care have been created to provide optimal regional care for patients with acute myocardial infarction and trauma.¹⁸ Drawing from these local programs and incorporating successful components into the stroke system of care can accelerate optimal stroke care models.

Planners of a stroke system of care should consider the term stakeholders in a very broad sense. Stakeholders should draw from key constituents, broadly healthcare providers, patients, caregivers, hospitals, home health companies, regulatory agencies, and payers.¹⁹ Healthcare providers should represent the major types of physicians, nurses, and allied health providers who are engaged in the care of stroke patients.²⁰ For acute care systems, important physician specialty stakeholders commonly include emergency physicians, vascular and general neurologists, neurosurgeons, neuroradiologists, neurointensivists, and hospitalists. Important nursing stakeholders include emergency care and neuroscience nurses, speech/language pathologists, and stroke center coordinators. Important allied health stakeholders include paramedics and emergency medical technicians. For prevention systems, important additional physician specialty stakeholders include internists, geriatricians, and cardiologists; additional stakeholders include behavioral psychologists, nutritionists, and urban and regional planners. For rehabilitation and recovery systems, important additional physician specialty stakeholders include physiatrists and neurorehabilitation neurologists. Additional stakeholders include physical, occupational, and speech and language therapists; rehabilitation nurses; social workers; and home health agencies. Hospital representation from across the range of geographic areas within the region and across a broad scope of hospital types should be involved. State and regional health policymakers, including the US Department of Health and Human Services; US Department of Transportation, National Highway Traffic Safety Administration's Office of Emergency Medical Services; Federal Office of Rural Health Policy, Health Resources and Services Administration, US Department of Health and Human Services; and key legislative champions if available, are essential and often lead the process. Rehabilitation personnel, including physiatrists and physical and occupational therapists in collaboration with nurse care coordinators, social workers, and home health agencies, among others, are essential to recovery throughout the continuum. Because there are multifaceted levels of rehabilitation, it is critical that rehabilitation team leaders representing various areas of rehabilitation are included in the system of care development. Patient engagement through either committed individuals or patient advocacy groups ensures that decisions are patient centered. Lastly, hospital administrators, hospital associations, and payers in the region help shape the economic discussions and should contribute to the program. The challenge for organizers is to ensure appropriate representation yet not create a group that becomes too large, unwieldy, and unfocused. Often, it is most efficient to first establish an acute stroke system of care and then expand it to other stroke domains such as access to prevention, public education, and rehabilitation and recovery.

Multiple frameworks have been proposed to outline system-based actions taken to improve public health. A visual continuum of the 8 domains of a stroke system of care (as shown in Figure 1) demonstrates how each part affects tertiary disease prevention.²¹ As an algorithm for the health promotion to disease prevention continuum, opportunities to achieve better health consider not only environmental, cultural, economic, and social influences in a population but also the resources allocated for the provision of public health initiatives. Both cardiovascular disease and stroke are leading causes of death and adult disability.^22,23 Thus, they have been the focus of a multitude of national and worldwide primordial and primary prevention causes to reduce the downstream burden of these diseases and the associated lifelong sequelae that affect both patients and families. Stroke systems of care have championed these efforts.

Primordial prevention represents a paradigm shift for integrating resources and policies that target broader at-risk patient populations. Primordial prevention encompasses actions taken to inhibit health risk factors and subsequently to prevent chronic disease in selected or whole communities. Programs that address social conditions (inadequate housing and lack of access to primary care), health behaviors (sedentary behavior, smoking and exposure to smoking), or diet patterns (foods with high fat/high salt content) address the risk for developing hypertension, heart disease, obesity, and stroke from fetal development to older age.²⁴ Primordial stroke prevention has enjoyed the efforts championed by stakeholders that have addressed strategies to reduce hypertension, diabetes mellitus, heart disease, and obesity, all identified as major risk factors for stroke.

Primary prevention refers to the actions addressing established risk factors associated with specific diseases. It includes both population-directed strategies and targeting of individuals with specific risks. Healthcare providers and local and regional programs address commonly known risk factors for chronic disease by either prescribing specific protection measures (prescribing antihypertensives for high blood pressure, prescribing aspirin for patients with stroke risk factors) or promoting healthy behaviors (supporting smoking cessation programs).^25–27

Within the past 2 decades, a multitude of local, state, and national campaigns were launched to increase stroke awareness and to reduce stroke burden in communities across the United States. A look back at the success of the US Department of Health and Human Services 2010 Healthy People initiatives shows a reduction in stroke deaths by 23% (from 62 to 42 deaths per 100 000).²⁸ The follow-up Healthy People 2020 initiative aims to improve cardiovascular health of Americans by 20% and to reduce cardiovascular events by 20%.²⁹ The AHA recently prioritized primordial and primary prevention policies for heart disease and stroke by promoting access to healthier (reduced sodium) and less costly foods, improved food labeling, and physical exercise programs in schools and the workplace.²⁴ The US Department of Health and Human Services launched its Million Hearts Program to prevent 1 million heart attacks and strokes through science, quality, and safety programs; partnerships with private sector groups; and public policy and multimedia marketing efforts.³⁰ The AHA published a policy statement to increase awareness of the social determinants of risk factors and outcomes for cardiovascular disease, offering recommendations for research on effective interventions.³¹

Despite these efforts, gaps remain in the application of many public health practice recommendations to the routine care provided by primary healthcare providers and to the health habits of many individuals in developed and developing countries.

Clinicians, policymakers, and numerous courageous stroke survivors play a key role in supporting the “pyramid base” by promoting programs that prevent the emergence of risk factors for developing disease.³² The 2005 AHA/ASA recommendations for the stroke systems of care task force listed primordial/primary stroke prevention as 1 of 7 required elements of an organized stroke system.¹ The 2013 AHA/ASA policy statement on interactions with stroke systems of care included the recommendation that health authorities, including government agencies, support the certification of stroke centers as a valid means to improving patient care and stroke outcomes.² National campaigns to end stroke (eg, “Target: Stroke” and “Together to End Stroke”) and to consider a lifestyle choice (eg, “Life’s Simple 7”) have become common slogans at health fairs.^33–35 Nationally certified acute stroke-ready hospitals (ASRHs), primary stroke centers (PSCs), thrombectomy-capable stroke centers (TSCs), and comprehensive stroke centers (CSCs) are required to engage in community programs that increase stroke awareness, stroke risk factor modification, and lifestyle changes.

A mature local, regional, or national stroke system of care must incorporate primordial/primary prevention. It is important that disparities in access to prevention care be identified and targeted for corrective action. For example, adult blacks are known to be at twice the risk for stroke given that more than half have ≥2 vascular risk factors.^11,36 Therefore, more preventive efforts and resources are required for these populations. Data on the prevalence of obesity, diabetes mellitus, and cardiovascular disease reveal that Hispanics and blacks are twice as likely to have any one of these comorbidities that can lead to stroke.³⁷ Several chronic disease care models are currently being tested as a potential solution for improving patient outcomes with cerebrovascular disease.³⁷

A stroke system should emphasize support tools and measures designed to enhance provider awareness of stroke prevention strategies and current evidence-based treatment recommendations. Providers should be encouraged to and assisted in initiating primordial and primary prevention strategies and in putting in place referral plans that conform to recognized stroke treatment recommendations. Communities are encouraged to use all available resources, including public health departments, to ensure optimal stroke care, and public policy initiatives should support such efforts.

Comprehensive support mechanisms should incorporate multiple strategies that target both providers and patients, and these strategies should take into consideration cultural and geographic customs. Education and practice tools should be developed with health literacy targets appropriate to the linguistic needs and education levels of the targeted population. These frameworks should be designed to support providers in monitoring current stroke prevention recommendations. Useful support tools may include disease management programs and medication adherence interventions.

A necessary component of integrated stroke systems of care is a commitment to a forum for public awareness and education that spans primordial and primary stroke prevention topics, stroke symptom recognition and response algorithms, and secondary stroke prevention and rehabilitation and recovery strategies. Educational initiatives should target broad age groups, various socioeconomic stations, numerous racial/ethnic demographics, multigenerational families, coworkers across a variety of workplaces, and wide geographic locations. Prevention efforts must involve primary care physicians and advanced practice practitioners. Nontraditional sources of public education and preventive care, such as urgent care centers and emergency departments, should also be engaged because they may be the only points of medical contact for populations with poor access to primary care. Campaigns focusing not only on stroke symptom recognition but also on stroke preparedness, addressing health literacy and cultural tailoring to neurologically underserved communities, have demonstrated considerable promise.

Public awareness campaigns are a popular venue for raising awareness and understanding of various health-related topics. With the approval of alteplase as an acute treatment option for ischemic stroke in 1996 and with the establishment of PSC certification standards in 2003, many efforts on local, regional, and global fronts have occurred over the past decade to promote stroke awareness.^33,34,38,39 These efforts have triggered interest in tracking patient-related and system-related outcomes, cultural and behavioral attitudes toward recovery, and public support for further epidemiological and translational research.⁴⁰

In the United States, ASA public educational and awareness campaigns to reduce the incidence of stroke have been extensive. In 2006, Power to End Stroke was created to reduce stroke and the risk of stroke. It was specifically designed to raise awareness in high-risk communities such as the black population.³⁹ “Stroke’s No Joke” was a public service announcement campaign launched in 2009 to inform blacks about stroke warning signs and the urgency to seek care (by calling 9-1-1).⁴¹ Using black stand-up comedians, this campaign addressed cultural competence, racial disease disparities, and social influences that shape relationships between individuals and the medical institutions.⁴¹ In an analysis of the 2014 National Health Interview Survey, age-adjusted stroke awareness was 66%, and stroke awareness was lowest for Hispanics, blacks, and those residing in the western United States; the least recognized stroke symptom was sudden severe headache.⁴² In 2013, the ASA, along with several industry sponsors, launched Together to End Stroke to increase awareness of stroke across the entire continuum of care, including prevention, acute treatment, and poststroke rehabilitation.³⁴ Built into this program was a hip-hop video competition to attract younger members of communities to join the campaign. The effectiveness of each individual campaign is unknown, but the disease-specific campaigns fit within the context of the larger US Department of Health and Human Services Healthy People 2010 and 2020.^{28,29,33,34,38,39,41}

Community-based participatory research is a newer approach to enduring engagement of communities addressing factors limiting positive health behavior. For stroke, prior research has consistently found that although stroke knowledge was important, it was not enough to significantly improve health behavior.⁴³ Other factors limiting an individual’s decision to access health care also likely influence behavior. Several innovative projects have focused on community education to address specific barriers within the stroke system of care. Focused on why patients do not receive timely acute stroke treatments, “Stroke Ready,” a community-academic partnership in Flint, MI, has piloted interventions in the black community to improve stroke preparedness in order to decrease prehospital delay and to increase local stroke treatment rates.⁴⁴ Using community engagement and partnerships, Stroke Ready increased appropriate stroke responses, including stroke recognition and individuals’ recognition of their own barriers that influence behavior (eg, willingness to call 9-1-1). The ASPIRE project (Acute Stroke Program of Interventions Addressing Racial and Ethnic Disparities) in the District of Columbia is another project using a community-engaged approach to stroke preparedness such as decreased stroke presentation times and increased thrombolysis use, targeting underserved black communities.⁴⁵ To measure improvement in acute treatment rates, large-scale interventions, such as the TLL (Thomas Lewis Latané) Temple Foundation Stroke Project, which was a large community-based grant to improve stroke awareness and treatment in East Texas, or others, are needed to demonstrate the effectiveness of community stroke preparedness interventions.⁴⁶

There is a recognized need for a new conceptual model for behavioral theoretical interventions for the prevention of stroke. Despite major advances in acute stroke treatment, there remains a mismatch between poor health outcomes for stroke and the high spending on services provided. Stroke is an obvious target for focused interventions because 10 of the stroke risk factors are associated with roughly 90% of the population-attributable risk of stroke around the world across race, ethnicity, sex, and age.⁴⁷ Current social and behavioral factors leading to risk factors for ischemic and hemorrhagic stroke have been studied, but our current interventions are insufficient to address and implement long-term change. Promising new paradigms based on social cognitive theory are emerging that are patient-centered principles and predictors that may inform and motivate people to adopt healthy lifestyles.⁴⁸ Once societal organizations and individuals jointly take on accountability for healthy behaviors, potential barriers to implementation and participation can be identified, and then new tools and technology that currently exist and pervade modern society can be brought to bear on this challenging problem.

First, the use of available technology for the passive surveillance and evaluation of patients’ behaviors may be used to establish a baseline and to measure future change. Second, media and social network applications (eg, Facebook, Twitter, Instagram, Snapchat) are all available channels to engage individuals, to increase the visibility of healthy behaviors by role models, and to modify positive or negative reinforcement through posts and sharing. Third, behavioral economics (ie, the study of how individuals make successful and unsuccessful attempts to pick best options) and gamification to alter behavior (eg, use of pedometers or calorie devices to challenge individuals and groups toward positive healthy behavior) are novel strategies that should be considered in policy change. The availability of social cognitive theory and the emergence of pervasive digital tools offer tremendous opportunity for future medical behavioral interventions.⁴⁰

These ongoing activities represent advances in the efforts of stroke systems to integrate existing and novel educational initiatives to improve public education focused on stroke symptoms, treatment options, and specifically how rapid care can significantly increase the percentage of patients eligible for acute reperfusion therapies. In the future, local, regional, and national stroke systems must expand such efforts to the entire continuum of stroke care from primordial prevention through recovery. Recognition of the historical barriers to stroke education, underserved at-risk populations, novel educational methodology, and existing social media technology may allow more enduring changes in behavioral responses to both individual and community stroke knowledge.

Currently, only ≈50% to 60% of hospitalized stroke patients arrive at the hospital via EMS.^49–51 Racial/ethnic minorities are less likely to use EMS.⁵² Given poor stroke awareness among US adults, with the lowest awareness among Hispanics and blacks,⁴² lack of knowledge of the risk factors and of the signs and symptoms of stroke remains a hindrance to timely stroke care. After EMS is activated, limitations in the accuracy of prehospital stroke assessment tools and in the timeliness of prehospital care to facilitate access to appropriate hospital care persist.

Given recent advances in the management of acute ischemic stroke, hospital-based acute stroke treatment must involve efficient processes of care to ensure the timely identification of stroke patients who may benefit from the effective delivery of thrombectomy by qualified providers in the right hospital. Furthermore, cases of large hemispheric or cerebellar ischemic stroke and hemorrhagic stroke, including aneurysmal subarachnoid hemorrhage (SAH), arteriovenous malformations, and spontaneous intracerebral hemorrhage (ICH), must be managed in hospitals with dedicated neurosurgical and neurointensive care services. With this recognition, a 3-tier system of hospital certification has emerged in stroke systems of care over the past 20 years. Recent advances have led to further refinement of stroke hospital systems to include the additional designation of TSCs. In the next sections, we discuss current hospital certification, recent advances in hospital-based stroke management, and emerging solutions to the implementation of scientific advances in routine clinical practice.

The postacute period of the stroke continuum is critical because of the importance of early rehabilitation to enhance recovery, improved transitions of care to reduce readmission, and early follow-up to continue and refine secondary prevention to reduce recurrent stroke risk. Secondary prevention of stroke has improved over the past 5 decades, mostly as a result of improved use of antithrombotic therapy and blood pressure management.¹⁰⁰ Since the previous publication, inpatient quality measures have been instituted that are required by all hospitals for public reporting purposes. This has resulted in a more standardized approach to subacute stroke care, and adherence to these measures has improved over time.¹⁰¹ For postacute stroke, the Centers for Medicare & Medicaid Services (CMS) mandated all-cause 30-day readmissions penalties for hospitals that exceed the national risk-adjusted readmission rate in 2016.¹⁰² Recent evidence has shown that a small proportion of readmissions are preventable¹⁰³ and that some planned readmissions may be warranted but still are penalized according to the CMS definition.¹⁰⁴ Advocates for further refinement of the determination of 30-day readmission rates (and other quality measures) are concerned that the calculation of readmission rates without initial stroke severity (ie, the National Institutes of Health Stroke Scale) will lead to misclassification of hospital performance and therefore misappropriation of resources.⁹³ Although the focus of processes to reduce readmissions has been on hospital-related factors, the social, functional, and community determinants of health are likely to be factors important in later (>7 days after discharge) readmissions that appear to be unrelated to hospital quality.¹⁰⁵ Given the uncertain impact of making changes to processes of care to reduce readmissions, the focus of postacute care should be on reducing mortality, maximizing recovery, and preventing recurrent stroke and cardiovascular events.

A comprehensive pathway for stroke care called the Global Stroke Services Action Plan was published in 2014.¹⁰⁶ This action plan is inclusive of the US stroke quality measures but is more extensive because it covers stroke care across the continuum. For transitions of care, the action plan recommends, “Patients, families, and informal caregivers should be provided with information, education, training, emotional support, and community services specific to the transition they are undergoing.”¹⁰⁶ Although this practice is likely commonly achieved in the inpatient rehabilitation setting before discharge, it is less common on discharge from the acute hospital setting, where the length of stay may be ≤4 days.

Despite the progress that has been made in the past 10 years, there are still gaps in and challenges and barriers to improving postacute care and secondary prevention. One of these barriers is the lack of structure in the paths that stroke patients and caregivers experience. An important aspect of postacute specialized care is screening for and avoiding stroke complications, which can include falls, venous thromboembolism, recurrent stroke or TIA, extension of an existing infarct, hypotension/hypertension, infections, cardiac complications, dehydration, and renal failure. Although some of these complications are addressed in the hospital with current quality metrics, there are no US hospital measures of the quality of postacute care designed to reduce these complications and to ensure that secondary prevention is followed after discharge. However, the Global Stroke Services Action Plan provides an evidence-based framework for hospitals to meet these specific quality indicators.¹⁰⁶

Access to postacute stroke services is another major barrier to equitable outcomes after stroke. There is wide geographic variation in access to postacute services for stroke patients, particularly postacute facilities and home health care.¹⁰⁷ A study of contemporary trends from 2003 to 2011 showed that overall 44% of patients are discharged home without any postacute services.¹⁰⁸ Alarmingly, 65% of stroke survivors <65 years of age were discharged without any postacute care services.¹⁰⁸ In addition, geographic disparities have been assumed to affect the quality of stroke prevention. However, the designation as a health professional shortage area was not associated with statin use, as shown in the REGARDS study. In fact, the lack of insurance appeared to decrease the likelihood of adequate access to stroke prevention medications, not designation as a health professional shortage area region alone.¹⁰⁹ The variation in access to services based on insurance (or lack thereof) and age <65 years suggests that many patients who should receive services are denied access, and this could have a significant negative effect on both recovery and secondary prevention.

Stroke education is an essential part of the postacute transition and includes not only what to do if stroke symptoms recur but also how to manage stroke risk factors; medications; appointments for primary care, specialists, and therapy; home safety; and lifestyle changes. Stroke education at discharge is a quality measure and publicly reported. However, stroke education in the postacute transition is even more important because of the overwhelming amount of information that patients and caregivers receive during their hospital stay and the information needed to adapt to the community.¹¹⁰ A recent scoping review of postacute services for patients with mild stroke concluded that services that provide education related to maximizing participation in secondary prevention is an area (among several) that requires more development and assessment in this population.¹¹¹

Emerging solutions to these challenges and barriers are on the horizon. A model of transitional care provided by a trained stroke nurse practitioner and a registered nurse showed that a systematic assessment of stroke complications reduced 30-day readmissions.¹¹² After adjustment for important confounders, being seen in this specialized transition clinic was associated with a nearly 50% reduction in 30-day readmissions compared with not being seen there.¹¹²

Early supported discharge is another model of transitional care in which patients are discharged home early and receive rehabilitation and specialized stroke services from a hospital-based multidisciplinary team that includes physical and occupational therapists, nurses, a social worker, a stroke neurologist, and personal aides.¹¹³ An important premise of early supported discharge is the use of community services. Stroke systems of care should be connected not only with outpatient therapy and home health care but also with other services that can support patients and caregivers and allow sustained improvement,¹¹⁴ similar to the recommendations of the Global Stroke Action Plan.¹⁰⁶ These services include community exercise programs, fall prevention programs, behavioral health, pharmacy services, stroke/caregiver support groups, risk factor self-management, local agencies that provide nutrition and transportation services (such as provided by the Area Agency on Aging), and handoffs to primary care.¹¹³

A new model of care that includes a patient-centered approach to both postacute care and secondary prevention is the Comprehensive Post-Acute Stroke Services model, currently being compared with usual care in 41 hospitals across North Carolina in a cluster-randomized pragmatic clinical trial.¹¹⁵ This model screens for postacute complications but also assesses the medical, social, and functional determinants of health and provides each patient with an individualized care plan that includes only the services needed for that patient at the point of care. A unique facet of this program involves the development of a community resource network located at each hospital participating in the trial, so that services can be mapped to a patient on the basis of what is available to that patient locally. The primary outcome of this trial is functional status, but rates of 30-day readmissions and multiple aspects of secondary prevention will also be determined.

The use of community health workers is also an emerging trend in healthcare services in the United States. In a systematic review of 34 published studies, the overall impact of community health worker intervention was variable, but 5 randomized trials showed a significant reduction in ≥1 emergency department visits, hospitalizations, or urgent care visits.¹¹⁶ The ongoing SUCCEED trial (Secondary Stroke Prevention by Uniting Community and Chronic Care Model Teams Early to End Disparities) will provide evidence for the use of an advanced practice clinician–community health worker team for secondary prevention after stroke.¹¹⁷

Rehabilitation remains the primary means by which a stroke survivor recovers maximal function. As shown in Table 2, stroke rehabilitation and recovery occur in various care settings.¹¹⁹

The Commission on Accreditation of Rehabilitation Facilities developed a Stroke Specialty Program that encompasses inpatient, outpatient, home and community, residential, and pediatric rehabilitation programs. Standards seek to minimize impairments, secondary complications, and environmental barriers; to reduce activity limitations; to maximize participation and quality of life; and to prevent recurrent stroke. The Joint Commission Disease-Specific Care Certification in Stroke Rehabilitation uses performance improvement to identify and address improvement opportunities, implements and graphically depicts a performance plan over time, and reviews the effectiveness of the interventions implemented in response to improvements identified by measurement activity.

Practice guidelines for stroke rehabilitation are well established and recommend that stroke survivors receive rehabilitation at an intensity commensurate with anticipated benefit and tolerance.¹¹⁸ However, access to rehabilitation services remains a major barrier. Availability of postacute care settings (especially in underserved areas), prospective payment variability, regulatory practices, the pressure to discharge patients rapidly from acute care, race, ethnicity, and sex all may influence if and where rehabilitation services are provided.^{107,120–126} Uninsured stroke survivors may remain in acute care longer because of problems in transferring them to inpatient rehabilitation settings.¹²⁷ Thus, it is not surprising that a recommendation from the “Interactions Within Stroke Systems of Care” policy statement emphasizes that “…all patients have access to post-stroke care (discharge planning services, rehabilitation, nursing facilities, medical follow-up) regardless of their financial status or socioeconomic background.”²

How stroke survivors are assessed for rehabilitation may also be problematic. Although PSC standards require that stroke survivors be assessed for rehabilitation services, 60.4% of stroke survivors <65 years of age and 37.5% of those ≥65 years of age were discharged home without rehabilitation services between 2003 and 2011.¹⁰⁸ There are many reasons for this phenomenon. Providers may be tempted to use no measurable deficits on the National Institutes of Health Stroke Scale as a guide to determine the need for rehabilitation services, but stroke survivors scoring a zero on the National Institutes of Health Stroke Scale may exhibit discernible motor deficits on the upper limb Fugl-Meyer and the Arm Motor Ability Test,¹²⁸ as well as truncal ataxia, headache, vertigo, and nausea after posterior circulation strokes.¹²⁹ Thus, standardized neurological, functional, and psychosocial assessments are needed to ensure that these and other issues are not missed.

Finally, a single dose of postacute rehabilitation does not meet the needs of all stroke survivors. Sufficient evidence has demonstrated that chronic stroke patients benefit from additional rehabilitation therapy.^130,131 Existing models of the prediction of rehabilitation potential explain less than half of the variance in recovery after stroke.¹³² Thus, stroke survivors need to be assessed functionally throughout their lifetimes to prevent readmission, to maintain fitness, and to prevent secondary complications.¹³³

The use of a standardized evaluation provides important insights into the type and duration of rehabilitation therapy needed on a patient-by-patient basis. Evaluations for stroke rehabilitation should include a neurological assessment of residual deficits; an assessment of functional (activities of daily living), cognitive, and psychological status; and determination of previous functional status and medical comorbidities, the level of family/caregiver support, the likelihood of returning to community living, and the ability to participate in rehabilitation services.

Such an assessment should include the total number and types of beds available, the intensity of services provided in different settings, the presence of interdisciplinary coordinated teams, including the use of community health workers, and the adequacy of care coordination programs. This assessment should consider the current and future needs in the system for inpatient and outpatient care, including the relative mix among inpatient rehabilitation facilities, skilled nursing facilities, continuing-care retirement communities, home care services, and outpatient services.

The stroke system should ensure that patients are referred to the setting most appropriate to their clinical needs.

Of the nearly 800 000 reported strokes per year, ≈16% of patients will die of their stroke within the first 30 days. Of the nearly 6 million Americans who have survived a stroke, ≈30% are left with permanent disabilities. Given the serious and complex challenges they face, stroke survivors and their caregivers can benefit from palliative care that can be provided at any level of stroke care and optimizes quality of life throughout the continuum of stroke care by reducing suffering, promoting comfort, and preserving dignity. Therefore, the 2014 AHA/ASA scientific statement that addresses palliative and end-of-life care in stroke emphasizes that palliative care has much to offer when stroke care is clinically challenging and emotionally intense and when ethically complex medical choices are encountered.¹³⁴ Palliative care is not an alternative to offering life-sustaining therapies but supplements and enhances care delivery for stroke survivors, caregivers, and providers alike when facing serious illness.¹³⁴