Mind the Gap: Supporting Successful Care Transitions and Recovery after a Stroke

Mind the Gap: Supporting Successful Care Transitions and

Recovery after a Stroke

Janet Prvu Bettger, ScD, FAHA – [email protected] Associate Professor of Nursing and Senior Fellow in Aging

Faculty Affiliate, Duke Global Health and Clinical Research InstitutesJune 24, 2014

mailto:[email protected]

All Rights Reserved, Duke Medicine 2007

Presentation Outline

• Burden of stroke• Systems perspective of stroke care • Evidence gaps • Care models for improved recovery from stroke


Projected Deaths by Cause for High-, Middle- and Low-Income Countries

Other NCDs

Cancers

CVD


Burden of Stroke: DALY

Johnston et al. Lancet Neurol 2009;8:345-54

Leading cause of serious, long-term disability in the US


Burden of Stroke in the United States (US)

• Incidence: 795,000 new or recurrent stroke each year

• Every 40 seconds someone in the US has a stroke• Every 4 minutes, someone dies of a stroke• 3 of 4 stroke survivors are dependent at some level for self-

care • Over 60% of stroke patients have cognitive impairment• About 15%-30% are permanently disabled• Stroke survivors requiring constant care 3 months following

their stroke have a 7-fold increased 1-year mortality risk

AHA Heart Disease and Stroke Statistics 2014 Update/ CDC National Vital Statistics Reports 2010


Challenges Specific to Stroke Care

• Average length of acute hospital stay = 4 days• Episode of care for stroke = 82-109 days• Almost 80% of stroke patients experience more than

two transitions of care after hospital discharge • 1 in 3 are rehospitalized within 3 months• 1 in 3 are institutionalized in a nursing home within 6

months


WHERE ARE OUR INTERVENTION POINTS?

Once someone has a stroke…


Community

ResponseEMS Acute Care

Rehab & Recover

y

Stroke System of Care and Transitions in Care


A Critical Intervention Point

Olson DM, Prvu Bettger J, Alexander KP, et al. AHRQ 2011

General Population

PopulationAt-Risk

Acute Care

Post-AcuteCare & Rehab

Living in Community

Living in LTC

The Transition to Post-Acute Care


Medicare Beneficiaries: Comparing patients’ 1st post-acute setting for all dx to stroke

D/C to PAC IRF SNF LTAC HH Outpatient0

10

20

30

40

50

60

70All Medicare

Stroke

Inpatient Community

%


Evidence-based Information is Lacking to Guide Delivery of Stroke Care After Hospital Discharge

• What services should a stroke patient receive after being hospitalized for an acute stroke? – Compare post-acute and transitional care

treatment options that matter to patients and their caregivers

– Focus on outcomes of interest to patients and their caregivers

• What strategies should be in place to improve the transition from inpatient care and improve longer-term outcomes?



Services After Acute Care


153,775 Acute Ischemic Stroke Patients in GWTG w/ Medicare FFS Parts A+B Alive at Hospital

Discharge (2006-2008)

51.1% Discharged to Short-term

Inpatient Post-acute Care

24.1% Inpatient Rehabilitation Facility or Unit

(N=37,064)

27.0% Skilled Nursing Facility

(N=41,457)

48.9% Discharged from the Hospital to the Community

14.9% Home Health

(N=22,875)

7.1% Outpatient Rehabilitation(N=10,982)

26.9% No Post-acute Care

(N=41,397)

Care Following the Acute Hospitalization


A TREMENDOUS OPPORTUNITY

…to generate key evidence that can be used to guide a critical decision faced by stroke survivors, their caregivers and health care providers every day, almost 1 million times a year…

what services to choose following an acute stroke hospitalization

?


Specific Aims (what we promised we would do … at a high level)

1. Identify the factors associated with stroke survivors’ use of rehabilitation and health care services following hospital discharge (who gets what services and why based on our data)

2. Compare high intensity rehabilitation (provided in inpatient rehabilitation facilities; IRF) and low intensity rehabilitation (provided in skilled nursing facilities; SNF) on several outcomes

3. Compare outpatient (OP) rehabilitation and home health (HH), and how either are better than no rehabilitation.

4. Compare PCP and neurologist follow-up on outcomes


Who are we studying and how?

This is a study using existing data of adults who had a stroke in 2006-2008.

The person had to have been treated in a hospital participatingin the Get With The Guidelines-Stroke program.

The person had to be a Medicare fee-for-service beneficiary for health care.

Some were in a prospectivecohort study, AVAIL.

PCORI Population

AVAIL Cohort

Medicare FFS

GWTG-Stroke


Outcomes from Claims Data

Outcomes Definition Timing

Hospital readmission All-cause readmission 30 and 90 days

Time to hospital readmission

Time in days from index hospitalization to readmission

Up to 12 months

Long-term care placement Nursing home = residence (nursing facility assessment CPT code AND place of service code with no associated SNF claim)

12 months

Survival (analyzed as death) Mortality (alive/not; will use for death & disability)

12 months

Survival Time in days from index hospitalization to date of death

Up to 12 months

Home-time Number of days from hospital discharge to 12 months without inpatient services, a rehospitalization or LTC admit

Up to 12 months

Health care utilization (proxy for cost)

All billable services (inpatient days, ED visits, observation stays & provider visits)

30 and 90 days


Patient Reported Outcomes

Outcomes Definition Timing

Primary: living independently Alive, community-dwelling, modified Rankin (mRS) 0-2 3 &12 mo.

Functionally independent mRS 0-1 3 &12 mo.

Change in function +/- 1 or > change in mRS from 3 to 12 months 12 months

Depression PHQ-8 >10 3 &12 mo.

Persistent depression PHQ-8 >10 at 3 and 12 months 12 months

Return to work Employed pre-stroke and returned to work 3 &12 mo.

Medication adherence Actions correspond with hospital provider recommendations (warfarin, antihypertensive, antiplatelet, lipid-lowering, and diabetic medications)

3 &12 mo.

Smoking cessation Actions correspond with hospital recommendations 3 &12 mo.

Quality of life Normalized EQ-5D 3 &12 mo.

Change in quality of life Change in EQ-5D score from 3 to 12 months 12 months

Death and disability Composite outcome 12 months


Soon we’ll have clearer evidence of what services for which patients…

But how do we support them along the journey back home?


STROKE TRANSITIONS IN CAREA look at care across the continuum…


Most Common Trajectories or Patterns of Care

There were 3,016 unique care patterns in the 120 days after an acute ischemic stroke



Discharged to Short-term Inpatient

Post-acute Care

24.1% Inpatient Rehabilitation Facility or Unit (N=37,064)

5.3% IRF only 19.9% IRF + HH

8.0% IRF + HH + OP

6.2% IRF + HH + Readmit

+ SNF or + HH

After Readmit

16.0% IRF + OP

8.4% IRF + SNF

5.8% IRF + SNF + HH

27.0% Skilled Nursing Facility (N=41,457)

30.5% SNF only

21.0% SNF + Readmit

+ SNF or + HH/OP

After Readmit

19.0% SNF + HH

5.2% SNF + HH + Readmit

+ SNF After Readmit

11.5% SNF + OP



Discharged from the Hospital to the Community

14.9% Home Health(N=22,875)

63.2% Home Health only

20.8% HH + Readmit

+ HH or

+ SNF After Readmit

10.1% HH + OP

7.1% Outpatient Rehabilitation (OP)

(N=10,982)

77.0% OP Rehabilitation Only

26.9% No Post-acute Care (N=41,397)

52.6% No Post-acute Care (no readmission and alive at 120 days)

27.4% Readmitted after hospital d/c without post-

acute care

20.0% Died after hospital d/c without post-acute

care

?Involvement of

Primary and Specialty Care?


A Critical Intervention Point


General Population

PopulationAt-Risk

Acute Care


Living in Community

Living in LTC

The Transition to Post-Acute Care


Critical Intervention Points for Stroke Survivors


Acute Care


Living in Community

Living in LTC

Transitions


Gaps Identified By Observation, Provider and Patient Reports, and Research

Stroke Patients’ Needs

Hospital Discharge Planning

Rehabilitation Expertise

Stroke Patients’ and Caregiver’s Needs at Home

Community-based Care

Rehabilitation Expertise

Transitional Care

Interventions

GAP


Transitions are a National Priority• HHS Triple Aim: Better Care, Better

Health, Lower Cost• HHS Priorities = National Quality

Strategy: Efficiency, population/public health, clinical effectiveness and processes, care coordination, patient and family engagement, patient safety

• CMS: The right care for every person every time• Partnership for Patients: Reduce HAC

by 40% and readmissions by 20%


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• National readmission rate: 13.8%

• Hospital risk-standardized readmission rate (RSRR) range: 9.1%-20.6%

Stroke Readmission: Opportunity for Improvement


Shifting and Narrowing the Curve – How?


TRANSITIONAL CARE INTERVENTIONS

What is effective for stroke survivors?


TRANSITIONAL CARE

“the set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location”

Coleman et al., J Am Geriatr Soc 2003;51(4):556-7.


Transitional care is…

• Supportive of patients during handoffs • A time-limited service • Focus on continuity • Commonly led by a nurse (more than 50% of interventions

summarized in systematic reviews were nurse-led)• An emerging key factor in care coordination


Poorly executed or discontinuous health care transitions increase the risk of

medical and medication errors, poor patient outcomes,

caregiver stress, and unnecessary services

Why is this important?


There are Many “TOC” Models

RED

BOOST

Care

TransitionsTCM

INTERACT

STARR

GRACE

BRIDGE


Core Interventions in Evidence-Based Transitional Care Models Interventions RED CTI BOOST TCM Bridge GRACE* INTERACT*Evaluation/risk assessment X X X X XMedications reconciled & plan confirmed X X XPatient education (with teach-back) on:

Diagnosis (daily) X X XCompleted tests & appropriate follow-up X“Red flags” and response to problems X X X X X

Patient education on medication management X X X XDischarge plan X X X X X

Written discharge plan or personal record X X X XDischarge plan reconciled with national clinical guidelines X XAppointments made for clinician follow-up, services , tests X X X XAppointments to be scheduled by patients X N/ADischarge summary (transition record) sent to post-discharge providers

X X X

Documented receipt of information by next provider X X

Telephone follow-up with patient to ID / resolve problems In 2-

3 Days

XIn 3 Days X

In 2, 30 days X N/A

Home visit X X X N/ATransitional care point person(s) X X XFacilitated engagement of patients, families, providers across episode X X

*GRACE is a community-based model; INTERACT is a nursing home-based models

Which Intervention?


Evidence of Effectiveness?


KNOWLEDGE GAPS


Knowledge Gaps

1. Do these work for stroke patients?2. Which strategies? (each intervention is multi-

component)3. Do we replicate these interventions? Adapt locally?

Integrate strategies from different interventions?4. Which transition or handoff?5. For what period of time?6. For which patients?


Transitional Care for Stroke: Roots in Policy

National Health Reform: Reduce

hospital readmissions

CDC commissioned a systematic review

Disseminated internationally

Wave 1: Heart Failure, Pneumonia, Myocardial Infarction

Proposed Wave 2: Stroke, Chronic Obstructive Pulmonary Disease

2012 Guidelines International Network2012 International Stroke Conference2013 International Association of Gerontology and Geriatrics


Do we have the evidence we need?Do these work for stroke patients?

?Very few of the nationally promoted care transitions

models included stroke patients. Of those that did, none presented findings for stroke

patients.




EARLY SUPPORTED DISCHARGE

Team based approach including caregivers to return stroke patients home earlier but with continued rehabilitation of similar intensity and duration to inpatient care


ESD Components

• Patient identified in acute care (or inpatient setting)• Discharged earlier• Home visit within 24 hours of hospital discharge • Goal-driven and patient-specific rehabilitation

delivered in the home• Services provided 4 x day (ESD phase), 6-7 days

week for up to 4 weeks and then reducing to weekly visits by the point of exit (at most 4-6 weeks)

• Different levels of engagement with stroke specialist (neurology)


Models of ESD

1. Stand-alone acute outreach ESD only– Prevalent in denser populated urban cities and where there are

large city hospitals2. ESD with community stroke/neurology team service

– In-hospital component hands off to a usually well established community-based rehab team partnering with neurology

3. Integrated ESD within community stroke team service– All the components of models 1 and 2, plus support workers for

rehab every day & multiple visits a day for up to six weeks4. Integrated ESD within community neurology service

– Often extends beyond stroke but then requires advanced skill set; prevalent in less urban areas

5. RECOVER trial– Nurse facilitated and organized, caregiver delivered


Evidence for ESD

• Multiple randomized controlled trials • Meta-analysis confirmed patients who received these services

returned home earlier (shorter inpatient length of stay) and were more likely to remain at home in the long term (longer “home time”) and to regain independence in daily activities (reduced death and dependency). – The best results with well organized discharge teams and patients

with less severe strokes.• International Consensus Guidelines and considered best practices in

UK and Canada– Canada ESD: $132.9 million direct cost savings.

• In the U.S.? – Failed and not feasible given payment model for services


Proposed US Model (Govt. focus = ↓ costs)

Reduce costs by 34%, saving $2.4 million over a 3 year period for

300 stroke patients

Reduce rehospitalizations

Improve patient functional status and

reduce secondary complications of stroke

Implement and optimize uptake of Early Supported Discharge as the new health care delivery model for post-acute comprehensive stroke

management

Reduce utilization of post-acute services (in skilled nursing facilities, inpatient rehabilitation,

and multipe episodes of home health care)

Improve self-management of stroke,

co-morbid chronic conditions and CV risk

factors

Integrate primary care with Early Supported Discharge to improve

access and transition care to community-based providers

Reduce long-term care nursing home placement

Improve patient and caregiver satisfaction

with post-acute stroke care

Transition to community-based wellness and exercise programs, and

case management as needed

“Task” shifting at 3 levels: rehab,

primary and community care


Not Quite a Global Perspective


General Population

PopulationAt-Risk

Acute Care


Living in Community

Living in LTC


Adapting ESD Globally

• ATTEND trial (Family-Led Rehabilitation after stroke in India)

• RECOVER trail (A randomized controlled trial on rehabilitation through caregiver-delivered

• nurse-organized service programs for disabled stroke patients in rural China)



What is appropriate for rural China?


52

A Randomized Controlled Trial on Rehabilitation through Caregiver-delivered Nurse-organized Service Programs for Disabled Stroke Patients in Rural China

REC VERThe

Trial


53

RECOVER Collaborating Institutions


54

RCT Study DescriptionIntervention and Control

Nurses from County Hospitals

Physicians / Rehabilitation Therapists

Training

♦ Intervention Group:

♦ Control Group: conventional care

Patients & family-nominated caregivers

Intervention

In-hospital• “Teach-back” on stroke recovery, risk

identification, and management• Task oriented training• Joint goal setting• Evidence-based discharge planning

Nurse + Patient + Family Caregiver

After hospital discharge• Call or visit at 2, 4, 6 and 8 weeks • Blinded researcher measures outcomes

by phone at 3 mo. & in person at 6 mo.


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HypothesesPrimary Hypotheses• To improve physical function

Secondary Hypotheses• To improve physical functioning• To improve quality of life• To reduce disability• To reduce depression

Exploratory Hypotheses• To relieve burden of caregivers• To reduce hospitalization • To reduce hospital length of stay &

costs

Primary Outcome• Barthel Index

Secondary Outcomes• Functional Ambulation Classification• EQ-5D• modified Rankin Scale• Patients Health Questionnaire-9

Exploratory Outcomes• Caregiver Burden Index• Re-admission and hospitalization• Hospital length of stay and medical

costs


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Study Design-Patient Recruitment

Inclusion criteria• Adults (≥18 years);• Recent (<1 month) first-ever acute ischemic/hemorrhagic/undifferentiated stroke

patients; • Expected to survive to discharge from hospital with a reasonable expectation of 6

month survival (i.e. not palliative, no evidence of widespread cancer etc.);• Residual disability (requiring physical assistance for core activities of daily living

defined as a Barthel Index score of 80 or lower).

Exclusion criteria• Unable to identify a suitable family-nominated caregiver for training and

subsequent delivery of care; • Unable to provide informed consent from both the patient (or by proxy) and the

caregiver.


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Zhangwu

Qingtongxia

Pilot and Main Study Samples and Sites

Sites:•Zhangwu County, Liaoning Province,

•Qingtongxia County, Ningxia Province

Pilot Study• Number of patients: 80 20 (I) + 20 (C) x 2 sites

Main Study• Number of patients: 200

100 (I) + 100 (C) (1/2 each site)


Complementary Models

RECOVER2.0

Telehealth

Transitional Care

Early Supported Discharge


Meeting the Needs of Stroke Survivors and Caregivers Globally

Many possibilities for efficacy and/or implementation effectiveness trials• Urban or rural• Single or multi-component strategy• Inpatient- or community-based or both• GPs or nurses or community workers or trained lay people• Mobile phones and ipads or centrally located computers• Intervention(s) to focus on functional impairment,

secondary prevention, or prevention of complications• Patients with or without cognitive impairment• Different levels of inpatient care• Different levels of caregiver engagement


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Why are we committed to this global research agenda?

• Improve the lives of stroke survivors• Reduce the burden on informal (family) caregivers• Improve adherence to evidence-based care• Improve the quality of care

• Improve physician-nurse partnership in the care of patients with stroke, disability, and chronic illnesses

• Build rehabilitation nursing capacity as leaders for caring for people with disabilities and chronic illness


Improving Stroke Outcome: It is going to take a

village


THANK YOU!

Janet Prvu Bettger, ScD, FAHA [email protected]

mailto:[email protected]

Documents

Mind the Gap: Supporting Successful Care Transitions and Recovery after a Stroke