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One Rehab Hospital’s Success Story
Using NDT to Improve Stroke Care and Outcomes


By Astrid Gonzalez-Parrilla, OTR/L


“Give life not exercise.” – Berta Bobath


The mission of the Rehabilitation Hospital (TRH) where I work as an OTRL is to provide the most efficient, outcome-oriented, and comprehensive medical rehabilitation services in Florida. We are a sixty-bed inpatient rehabilitation facility located in Fort Myers. We are accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF) and we worked hard to get designated as a Stroke Specialty Program. TRH is part of Lee Memorial Health System, which has five acute care hospitals, a children’s’ hospital, a regional trauma center, and a large multi-specialty physician group. Our vision is to be the best patient-centered healthcare system in Florida by balancing quality, access, and cost.

The commitment of the health system’s leadership team and our clinicians to provide high quality care and deliver excellent customer service to this community has ensured the success of our Clinical Stroke Team. With the anticipated progression of the “75% Rule,” which revises the Medicare payment criteria for classifying hospitals as inpatient rehabilitation facilities, the journey started as both a performance-improvement initiative and volume-development strategy. The system had certified two campuses as primary stroke centers. As members of the system-wide stroke team, we wanted to promote greater integration of our inpatient rehabilitation services into the stroke system of care.

The Performance Improvement (PI) team established dual goals for the stroke population. We wanted to increase accessibility to TRH for our acute-care stroke population, raising the stroke case mix to 22% of total admissions. We also wanted to invest in staff development strategies that would serve as a foundation for consistent improvement in outcomes for the stroke patient population. Assessment and benchmarking of data to peer groups confirmed that there were opportunities to improve clinical outcomes for stroke patients.

Discharges Before Using NDT Approach

Our challenge was that TRH’s discharge to the community was below that of the state and nation. We needed to develop a strong program that would guarantee high functional outcomes and excellent patient satisfaction while living within budget constraints. We had to invest our “resources,” both training hours and dollars, wisely.

Establishing NDT
Our management team decided to use Neuro-Developmental Treatment (NDT) as the theoretical foundation to create a Clinical Stroke Team. Specific goals for staff education and training were established. Presentations of the NDT approach to interdisciplinary team members and subsequent invitations to be part of the stroke clinical team met with success. The Clinical Stroke Team established a consistent weekly meeting schedule. It started with the therapy disciplines: occupational therapy, physical therapy, speech therapy, and recreational therapy. The excitement was contagious and extended the team, which now includes case management, nursing, and our psychologist.

Dedicated clinicians have initiated a study group using the Neuro-Developmental Treatment Approach Theoretical Foundation and Principles of Clinical Practice, the book and study guide published by the Neuro-Developmental Treatment Association (NDTA). We are committed to the concept of seeing the patient as a whole. We problem solve together in order to provide all of the necessary resources to meet the patient’s needs and expectations.

Initially the Rehabilitation Hospital, in a collaborative financial effort with the system’s rehabilitation services team, committed the collective resources to support education for a team of four therapists. Two occupational therapists and two physical therapists completed the three-week NDT course for management of adults with hemiplegia. The efforts continue. Now, 41% of all therapists in TRH have received formal NDT training, ranging from introductory courses to advanced courses. Five of our therapists are NDT trained and active NDTA members.

Discharges after Using NDT Approach.

The trained therapists have supported the broader interdisciplinary team by providing education to the nursing staff on the use of the NDT approach to determine techniques to perform transfers and positioning of patients in bed. Team members also reach out to provide ongoing education to the community regarding risk factors, signs, and symptoms of stroke. The team members demonstrate commitment not only to their professions, but also to the provision of excellent, outcome-oriented treatment for our stroke survivors.

We have an excellent group of clinicians that have accepted the challenge to commit the time and effort needed to complete their own education and training. They are now leveraging that knowledge and those skills to educate other members of the team and people in our community. We took to heart the principles that Mrs. Bobath believed in: focus on quality of life, use a problem-solving approach, and understand that NDT is a living concept. As a team we enjoy learning from each other and we are constantly mindful of the mission of our service: to provide the most efficient, outcome-oriented and comprehensive medical rehabilitation services for our patients.

NDT is the foundation for our approach to treatment. That foundation is making a difference. Today, we have successfully increased our stroke patient “discharge to the community” rate and also improved the durability of those outcomes as the patients move back to the community. The commitment from TRH to the community we serve has been strengthened. The team is also committed to the concept of lifelong learning. Even in these uncertain economic times, we will continue to invest in our therapists’ development and training around NDT as the theoretical foundation for our care. The chart (at left) paints our success better than a thousand words!

Since this article was first written, Lee Memorial Health system has taken the initiative to sponsor 13 more therapists to attend the Three-week NDT Course. By September of 2009, we will have a total of 16 NDT-trained therapist in the system working in acute care, inpatient rehab, and out patient.


Astrid Gonzalez-Parrilla, OTRL, works at Lee Memorial Health System. She can be reached at astrid.gonzalez-parrilla@leememorial.org.

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