Stroke Rehabilitation Care Pathway Informed by Time-Driven Activity-Based Costing

Stroke remains one of the most devastating health challenges worldwide, striking millions of people every year and leaving behind a heavy burden of disability and financial strain. For those who survive a stroke, the path to recovery often depends on rehabilitation—intensive therapy to regain movement, speech, and independence. In recent years, healthcare systems have increasingly turned to "early supported discharge" programs, which move patients from the hospital to their homes sooner, where they receive care from a team of specialists. To make these programs work, especially when the pandemic forced clinics to switch to virtual visits, doctors and administrators needed a way to understand exactly how much time and money these services truly cost. This is where a method called time-driven activity-based costing comes in. Rather than guessing at expenses or using broad averages, this approach breaks down every single task a patient receives, measures the exact minutes spent on each, and assigns a specific cost based on the salary and time of the professional performing it. It treats healthcare like a detailed ledger of time and effort, allowing researchers to see precisely where resources go and how different ways of delivering care change the bottom line.

In a study conducted in Quebec, Canada, researchers applied this meticulous accounting method to a stroke rehabilitation program that served adults in their homes. The team wanted to compare how the program operated before the pandemic, when all care was delivered face-to-face, against how it functioned during the pandemic, when virtual healthcare became a necessary part of the mix. They tracked 108 patients over a two-year period, following them from the moment they entered the program until they were discharged. The researchers mapped out every activity involved in a patient's journey, from the physical therapy sessions and nursing checks to the administrative meetings and travel time required to reach a patient's home. They then calculated the cost of every minute spent by doctors, nurses, and therapists, including both the time spent directly with the patient and the time spent behind the scenes planning care or documenting results.

The results revealed a significant shift in how care was delivered and how much it cost. In the year before the pandemic, the average patient received about 4,300 minutes of total care, which translated to a direct cost of roughly $4,049 per person. When the pandemic hit and virtual visits were introduced, the nature of the work changed. While the number of patients remained similar, the total time spent on each patient's care jumped dramatically to over 7,100 minutes. Consequently, the direct cost per patient rose to about $6,512. The study found that this increase was not due to higher salaries, but rather to the sheer volume of time required. Nurses and speech therapists, for instance, spent far more time on each patient during the pandemic years than they had the year before. The team also noted that the patients in the later period were slightly older and arrived at the program with lower levels of independence, which may have contributed to the need for more intensive support.

A key finding was that the introduction of virtual care did not simply replace in-person visits to save money; instead, it often added to the total workload. The researchers observed that the transition to telehealth required a cultural adjustment for both the staff and the patients. Many professionals were learning to use new technology for the first time, and patients often needed extra time to adapt to remote sessions. This learning curve, combined with the need to maintain high-quality care for older, more dependent patients, meant that the team spent more time on administrative tasks, case discussions, and preparation. The study showed that indirect costs, such as travel and supplies, remained relatively stable, but the human effort required to manage the hybrid model of care grew substantially. The total cost of running the entire program for the year with virtual care was significantly higher than the year before, rising from about $4,783 per patient to over $7,300.

The researchers concluded that while this detailed costing method is a powerful tool for understanding the true price of care, the data suggests that integrating virtual health into stroke rehabilitation is not a simple cost-cutting measure. Instead, it appears to be an intensification of services that demands more time and coordination. The study highlights that when a healthcare system shifts to a hybrid model, the complexity of managing care increases, leading to higher costs per patient. The authors suggest that this method of tracking time and cost is essential for program managers who need to make informed decisions about resource allocation. By seeing exactly where the extra time is going, leaders can identify opportunities to improve efficiency without compromising the quality of care. Ultimately, the work demonstrates that while virtual care is a vital way to maintain access during crises, it changes the economics of rehabilitation in ways that require careful management and realistic expectations.