DOD and VA Release New Stroke Rehabilitation Guidelines to Improve Patient Outcomes

In August 2024, the Department of Veterans Affairs and the Department of Defense released new clinical practice guidelines for the management of stroke rehabilitation for their health care providers.

The VA/DOD Clinical Practice Guideline for Management of Stroke Rehabilitation for 2024 updates guidelines published in 2019. The new guidelines provide comprehensive, evidence-based recommendations for the management of stroke rehabilitation.

Dr. Jenifer Meno, deputy chief, Defense Health Agency Clinical Quality Improvement Program/Medical Affairs/Clinical Support Division, explained that new guidelines were established because of new research and care for stroke rehabilitation in the past five years.

“In support of the interagency partnership of continual learning, recommendations from the VA/DOD clinical teams, congressional interest, and changes in medical treatment, the evidence-based work group updates or develops new CPGs,” said Meno.

The new guidelines aim to improve clinical outcomes by providing an evidence-based framework for evaluating and managing care for adult patients, 18-years or older, who have experienced a stroke.

“Clinical practice guidelines serve as the foundations for delivering safe, standardized, and quality clinical care,” said U.S. Public Health Service Capt. Margaret Rincon, chief, DHA Clinical Quality Improvement Program/Medical Affairs/Clinical Support Division. “These guidelines provide clinical care recommendations based on an expansive review of evidence-based research … bringing the knowledge and insights of the most recent clinical research to the fingertips of clinical teams.”

Rincon explained that CPGs provide a standardized approach to the delivery of care that is backed by research demonstrating improved or best clinical outcomes.

Meno said, “The clinical practice guideline includes evidence-based practice to support better outcomes provided to all beneficiaries. As an example, for stroke rehabilitation, there are tools to help patients and families with questions after a stroke ranging from communication with family and friends to resuming activities … each CPG provides tools that support the clinician and patients’ opportunity for shared decision making and address specific patient needs.”

Significant Updates to CPGs

The management of stroke rehabilitation work group, which prepared the document, stressed the importance that providers review this new version of the CPGs.

An updated algorithm and sidebars defining a clinical flow, and 24 new recommendations were some of the major changes made. Meno explained there were 19 previous recommendations that were replaced, three amended, and 16 recommendations that were deleted from the 2019 version.

The new algorithm format represents a simplified flow for the management of stroke rehabilitation patients and fosters efficient shared decision making by providers and patients, explained Rincon. It includes steps of care in an ordered sequence, decisions to be considered, decision criteria recommended, and actions to be taken. The algorithm is a step-by-step decision tree.

A major strength seen in this new guideline is the coordination and collaboration of multidisciplinary teams ensuring a broad representation of providers engaged in the management of stroke rehabilitation.

Patient-Centered Care

By representing a holistic approach to health care, the guidelines encourage providers to adopt a patient-centered, culturally appropriate delivery system that is also available to people with limited literacy skills and physical, sensory, or learning disabilities. According to the guidelines, regardless of the care setting, all patients should have access to individualized evidence-based care.

These CPGs also encourage providers to practice shared decision making, a process in which providers, patients, and patient care partners (such as family, friends, caregivers) consider clinical evidence of benefits and risks as well as patient values and preferences to make decisions regarding the patient’s treatment. Providers are encouraged to use shared decision making to individualize treatment goals and plans based on patient capabilities, needs, and preferences.

“CPGs support the priorities of building a modernized, integrated, and resilient health care delivery system, said Meno. “The CPGs also support the provision of providing excellence in patient-centered and evidence-based care.”

A Successful Implementation

The VA/DOD collaboration recommends several focal points for the successful implementation of this CPGs, including:
• Assess the patient’s condition and collaborate with the patient, family, and caregivers to determine optimal management of care
• Emphasize the use of patient-centered care and shared decision making
• Minimize preventable complications and morbidity
• Optimize individual health outcomes and quality of life

DHA’s Virtual Education Center Support CPGs

The DHA’s Virtual Education Center contains more than 50,000 education resources covering 60 medical topics, giving patients using a mobile device or computer with internet access to validated health and medical information.

According to Meno, the Virtual Education Center can significantly support CPGs in several ways, including:

• Access to up-to-date, validated information
• Provider support
• Provide patients credible health information
• Patient support
• Curated digital content packages aligned to the CPGs

“Overall, the VEC enhances the effectiveness of CPGs by providing accessible, validated, and up-to-date information to both health care providers and patients, improving compliance and health outcomes,” said Meno.

In collaboration with the VA, the DHA Clinical Practice Guidelines team updates, develops, and monitors 25 guidelines utilizing evidence-based practices. This partnership, along with understanding the needs of patients from both the military and veteran health care systems, leads to improved patient outcomes.

Rincon emphasized the “guidelines are designed to provide information and assist decision making and are not intended to define a standard of care and should not be construed as one. Neither should they be interpreted as prescribing an exclusive course of management.”

The guideline was prepared by the Management of Stroke Rehabilitation Work Group, with support of the VA Office of Quality and Patient Safety, and the DHA Clinical Quality Improvement Program.