Follow Up Stroke Care at Home: Beyond the Emergency Department

Darren Larsen, RN, BS, CNRN, SCRNOHSU Stroke Center

February 5, 2015

Conflict of Interest Disclosure

Disclosure

I do not have any financial relationship(s) todisclose.

Telemedicine and Stroke

Oregon Health & Science University (OHSU)• Telemedicine in the emergency department• Telemedicine in the home and clinic

Patient Case

OHSU Telemedicine Network

Stroke Prevention in the ClinicStroke Therapy, Education and Prevention

(STEP) at OHSU

• Nurse-led initiative begun in November 2011• Program based on protocols used for other stroke

prevention trials• Initiation of antihypertensives, statins, antiplatelets

where indicated• Education regarding diet, exercise, smoking cessation

and stroke warning signs and symptoms

STEP Initiative for Stroke Prevention

ISC 2013, Honolulu, HI

Prior to discharge• STEP nurse: patient medication and lifestyle education

Post discharge follow up• 7-10 days: Nurse call to review medication compliance and

reinforce education• 30 days post discharge: Seen in clinic where BP measured,

medications adjusted by stroke neurologist

STEP cohort compared to retrospective cohort matched based on STEP eligibility criteria for visit adherence and percentage achieving goal BPs at 30 days

STEP Initiative for Stroke Prevention

Follow up adherence

Blood pressures at goal

ISC 2013, Honolulu, HI

Stroke Therapy, Education, Prevention: Telemedicine Outpatient Initiative Trial

(STEP TO IT)Aims• Compares those evaluated using telemedicine in the home

using Cisco Jabber web based interface, that live more than 75 miles from OHSU to those seen during face to face appointments– Feasibility, blood pressure control, patient satisfaction– Secondary analyses explore other facets of stroke

prevention (lipids, lifestyle measures, etc.)

Stroke Therapy, Education, Prevention: Telemedicine Outpatient Initiative Trial

(STEP TO IT)• Started enrolling 18 months ago• 19 patients enrolled• 6 telemedicine,12 clinic

Telemedicine Setup• Printed instructions• Patient installs plug-in• Places a test “call”• Sent a link active during

designated time

Home Telehealth Visit with Patient

http://www.ohsu.edu/edcomm/flash/flash_player.php?params=1%60/host/telemedicine/tele_monitor5.flv%60vod&width=720&height=405

Stroke Therapy, Education, Prevention:

Telemedicine Outpatient Initiative Trial (STEP TO IT)

Telemedicine• Three complete (one by phone)• Two drop-out

• Cost• Declined further

participation

Telemedicine crossover due to technology

• Telemedicine came to clinic, did not return for 1 year visit

Clinic• Three complete• Two drop-out

• Insurance• Cost

STEP TO IT Challenges

• Overall– Funding– Lack of dedicated

resources– Weekend coverage– Research visits required

to return

• Telemedicine– Technology

• User difficulty• Interface downtime• Bandwidth• Population

– Reimbursement

In-home Follow Up: Beyond STEP TO IT

• 25 non-hospital encounters– In-home– 2 clinic locations– SNF– IPR

• iPad with Jabber

Telemedicine:Provider Perspectives

Telemedicine: Challenges/Limitations

• Testing reflexes/muscle strength• Visual field testing• Sensory testing• Miss subtle findings• Other people in the room can be distracting

Next Steps

• Continued growth in-home

• Stroke preventive care via telemedicine in clinic setting

• In place in 2 clinics, others in progress

Bringing stroke care to all Oregonians

Thank you!