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Kathy Morrison, MSN, RN, CNRN, SCRN
Alicia Richardson, MSN, RN, ACCNS-AG
Kari Moore, MSN, AGACNP-BC
Out of Sight, Out of Mind? Post Acute Strategies for Stroke
Care
Disclosures
• Kathy Morrison
• Kari Moore
• Alicia Richardson
• None
2
Objective
Describe key components of post-discharge
management and the implications on the
acute care discharge process.
When did we start to care about post discharge processes?
3
Accountable Care Organizations (ACO)
Hospital Readmissions
Reduction Program
Bundled Payment Care Improvement
(BPCI)
2012 2012 2014
Integrated health systems
Linking payment to quality outcomes--shift healthcare payments away from fee-for-service toward value-based reimbursement
Risk-adjusted readmissions within 30 days of discharge
Initially AMI, HF, PN, now expanded to include others
Episodes of care bundled together – financial and performance accountability
Precursor was HMO (1980’s) – unpopular; incentivized providers to limit services
Affordable Care Act (ACA)
aka “Obamacare”
Published Outcomes Data
• Nearly two-thirds of Medicare beneficiaries discharged after ischemic stroke died or were re-hospitalized within one year
• Causes of re-hospitalizations within one year
• Cerebrovascular disease- 11.4%
• Cardiovascular- 14.9 %
• Non-Cardiovascular- 73.7%
Fonarrow G et al. Stroke. Epub Dec 16, 2010
76.9%
32.5% 28.1% 23.7%
Common Co-Morbids
HTN CAD Diabetes A Fib
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Stroke Regulatory Standards
CMS: January 1, 2014 started the reporting on Stroke 30 day mortality rate and Stroke 30 day readmission rate.
• These measures will affect payment in FY 2016 (Oct 1, 2015- Sep 30, 2016).
• Reported as risk-standardized mortality (RSMR) and readmission (RSRR) rates
CSC: CSTK 2 – mRS at 90 days (IV tPA & MER pts)
7-day phone call for “complex” strokes
TJC Recommendations for Transitions in Care - Discharge
• Review roles of case management and social worker within stroke program
• New roles• Stroke Nurse Navigator
• Family Advocate
• Transitional Care Coordinator• Family training
• Scheduling of follow up visits before discharge
• Coordinating follow up referrals
• Interdisciplinary Rounds
– Integration of patient and family in
planning goals and discharge
– Main family contact for coordination
of record of contact
– List of all community integration
referrals
• Eligibility
• Documentation of referrals given
• Plan for follow up
2015 Joint Commission Stroke Certification Seminar
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Operationalized Standards
Pre-discharge
• Involve patients in decisions about their care• Daily rounds
• Assess patients’ self-management capabilities
• Nursing assessment, provider assessment, therapy evaluations, social worker assessment
• Assess family/caregiver readiness/willingness & ability to provide or support self-management activities
• Nursing assessment, social worker assessment
• Based on needs, patients are referred to community resources to facilitate integration into the community
• Social worker, care coordinator, case manager
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Home Acute Rehab LTAC SNF Hospice Death
Ischemic
SAH
ICH
Know Your Population
Discharge Disposition
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Severity Scores
0%
10%
20%
30%
40%
50%
60%
70%
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90%
100%
mRS at Admit
Grade 0Grade 1Grade 2Grade 3Grade 4Grade 5
Average NIHSS on admission: 12; Median: 5
Median: 0
0%
10%
20%
30%
40%
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60%
70%
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90%
100%
mRS at Discharge
Median: 3
Average NIHSS on discharge: 7; Median: 2
Admission DischargeIschemic
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
mRS at Admit
Grade 0
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Median = 1
SAH
0%
10%
20%
30%
40%
50%
60%
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100%
mRS at Discharge
Median =2
0%
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40%
50%
60%
70%
80%
90%
100%
mRS at Admit
Grade 0
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Median = 2
ICH
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
mRS at Discharge
Median = 3
30-day Readmissions
Stroke
Patients2013/2014
Avg
2013Jan 2014
Feb Mar Apr May June July Aug Sept Oct Nov Dec
Neurology 3.5(9%)
4(9%)
7(20%)
4(5%)
5(11%)
5(11%)
5(11%)
2(4%)
3(9%)
1(3%)
1(3%)
2(5%)
2(5%)
Neurosurg 1.3(7%)
3(14%)
5(38%)
2(9%)
0(0%)
0(0%)
0(0%)
0(0%)
0(0%)
1(8%)
0(0%)
1(5%)
0(0%)
Stroke
Patients2014/2015
Avg
2014Jan 2015 Feb Mar Apr May June July Aug Sept
Neurology 3.4(8%)
1(3%)
0(0%)
1(3%)
4
(7%)
0
(0%)
0
(0%)
1
(2%)
0
(0%)
2
(4%)
Neurosurg1
(6%)
0(0%)
0(0%)
1(5%)
0
(0%)
1
(5%)
0
(0%)
0
(0%)
0
(0%)
0
(0%)
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PSHMC
• 48 hour phone call to all stroke pts dc’d to home – RN,
outpatient care managers• Already part of organizational initiative to call pts
• Worked with care managers to ensure stroke-specific focus was followed
• 7 day phone call to all stroke pts dc’d to home- clinical pharmacist• Advantage found to waiting until after PCP visit
• 30-day, 90-day, 1-year stroke clinic visits• See @ 60% of ischemic strokes in clinic
• Limitations: 35% of pts are transferred from outside hospitals, often do not travel back for follow-up
• NH & LTACH pts rarely come to clinic
One PSHMC Strategy for Follow-up (not necessarily successful)
• Automated process for follow-up appts to be set up during
hospital stay• Based on admission diagnosis – to be canceled if diagnosis changed from
stroke/TIA
• Attempt to ensure that pts knew of appointments before discharge
• No-show rate for 30-day stroke clinic up to 20%• Automated phone reminder system
Yikes – looks one fix created another problem!
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Stroke Clinic Experience
Who Needs 30-day Clinic Follow-up? Probably not everyone
Population Stats:
• 53% male; median age 68, BMI 30
• 82% mRS 0-2, BI 90-100
• Location at time of visit: 87% home, 6% ECF, 5% rehab
• Events/complications: 38% none, 15% depression, 9%
falls
• Post Stroke Checklist results:
– 29% selected none, 56% yes to one item,29% yes to two items
• 69% Difficulty concentrating and remembering things
• 34% Feeling more anxious or depressed
• 22% New pain – shoulder/arm, back
• Actions taken:
– 31% Provider referrals made
– 14% Therapies, Driver Eval, Botox ordered
– 10% Med changes
Cryptogenic stroke
New A fib diagnosis
New Diabetes Diagnosis
Plan to restart meds
(Ex.Anticoags)
Repeat Stroke
Smoker
Bundled Payment Experience
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Successful Strategies for Post-acute Care
• Phone calls • Arrange for call prior to discharge is optimal
• At least let them know someone will be calling
• Concise list of topics to cover
• Clear instructions for phone numbers to be used if questions• Phone tree access for patients/caregivers for questions post discharge, or who
are returning calls
• Clinic visits
• Remote follow-up via telemedicine• Collaboration with outside hospital telestroke partner to have pt return there,
eval’d by neurologist or APC via two way audio/video
• Collaboration with PCP/community clinics for remote eval support
• Collaboration with area Rehab Hospitals and Nursing Homes• Education of staff may:
• Improve compliance with plan of care – meds, diet, activities, BP management
• Reduce rate of readmission to hospital – awareness of postural hypotension effect, timing of antihypertensives, level of fluid intake, etc
Successful Strategies for Post-acute Care
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U of L CSC Resource Utilization for the Continuum of Care
Stroke Service APRN
Day of Discharge Home
Neuroscience Outpatient SSW Outpatient Stroke
Coordinator
Inpatient Stroke
Coordinator
Documents Discharge mRS, BI,
NIHSS
Perform 7 day f/u phone call to
assess: prescriptions filled and
medication adherence, follow up
appointments made with providers,
outpatient rehab
scheduled/started, resources such
as DME acquired, and diagnostics
ordered at d/c scheduled
Schedules 30 day f/u
appointment in stroke clinic
Performs 90 day mRS
by phone on all stroke
patients and enter
into GWTG-S®
Verify Home Phone Number and
discharge address
Needs assessment performed at 30
day f/u visit in stroke clinic as
necessary
Documents 30 day mRS in
outpatient EHR and enter into
GWTG-S® at office visit or by
phone call
Trends mRS based on
etiology of AIS, acute
RX and discharge
disposition
Verify pt has prescriptions for
medications and any orders for
outpatient rehab or diagnostic
testing
Serves as a resource for healthcare
system navigation throughout the
continuum
Facilitates all further care and
diagnostics with provider
Facilitates
communication
among team
members for PI
initiatives
Public Health Approach to Transitional Care Programs
Purpose:
• Reduce readmission and recurrent stroke
Taylor Regional Hospital (TRH)
Lake Cumberland District Health
University of Louisville Comprehensive Stroke
Center (ULSC)
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• Stroke patients transferred from TRH to ULSC discharged home
• LCDHD nurses made 3 home visits at 2 weeks, 3 months, and 6 months to assess:
• biometrics
• Labs (A1C, lipid panel)
• blood pressure self-management
• verbalization of stroke symptoms
• behavioral modifications since hospital discharge
• self assessment of perceived health status
• Facilitate community clinical linkages
• Follow up phone call made at one year
Stroke Patient Education & Navigation (SPEN)Methods
Stroke Patient Education & Navigation (SPEN)
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SPEN Study Outcomes & Results
Outcomes Measured:
Primary Outcome:
All cause readmission rate within 30
days and one year
Secondary Outcomes:
1) Medication Compliance
2) Utilization of a community
Resource
Results:
• 44 participants (October 1, 2013-
March 31, 2015)
• 28 male, 16 female
• 32/44 completed all 3 visits
• 2/44 (5%) readmitted within 30 days
(1 TIA, 1 Pneumonia)
• 36/44 (82%) compliant with
medication
• 2/24 (8%) utilized a community
resource
• 10/44 readmitted within 1 year (3
vascular events –MI, TIA, HTN)
• Cost = $306.00/patient
Conclusions:
• The sample size was small and limited by
participants opting out of home visits at 3 and 6
months.
• The readmission rate of 5% is lower than reports in
the literature ranging from 6-33%.
• Future programs may consider long-term follow up
by phone.
• Further outcomes and cost analyses can be
obtained with a larger sample size and extended
follow up.
To Summarize…
• Know your hospital stroke population data
• Stay up-to-date with current standards – CMS and TJC
• Consider resource allocation changes/alternatives
• Think outside the box
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Questions?
Kathy Morrison
Alicia Richardson
Kari Moore
