Out of Sight, Out of Mind? Post Acute Strategies for Stroke Care Disclosures

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1 Out of Sight, Out of Mind? Post Acute Strategies for Stroke Care Kathy Morrison, MSN, RN, CNRN, SCRN Alicia Richardson, MSN, RN, ACCNS-AG Kari Moore, MSN, AGACNP-BC 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 Affordable Care Act (ACA) aka Obamacare Accountable Care Organizations (ACO) Hospital Readmissions Reduction Program Bundled Payment Care Improvement (BPCI) 4 Integrated health systems Linking payment to quality outcomes--shift healthcare payments away from fee-for-service toward value-based reimbursement Risk-adjusted readmissions within 3 days of discharge Initially AMI, HF, PN, now expanded to include others Episodes of care bundled together financial and performance accountability Precursor was HMO (98 s) unpopular; incentivized providers to limit services 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-.4% Cardiovascular- 4.9 % Non-Cardiovascular- 73.7% Common Co-Morbids 76.9% 3.5% 8.% 3.7% HTN CAD Diabetes A Fib FonarrowG et al. Stroke. Epub Dec 6, 3

4 Stroke Regulatory Standards CMS: January, 4 started the reporting on Stroke 3 day mortality rate and Stroke 3 day readmission rate. These measures will affect payment in FY 6 (Oct, 5-Sep 3, 6). Reported as risk-standardized mortality (RSMR) and readmission (RSRR) rates CSC: CSTK mrsat 9 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 5 Joint Commission Stroke Certification Seminar 4

5 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 selfmanagement 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 Know Your Population 5% 45% Discharge Disposition 4% 35% 3% 5% % Ischemic SAH ICH 5% % 5% % Home Acute Rehab LTAC SNF Hospice Death 5

6 Severity Scores % % 9% 9% 8% 8% 7% 7% 6% 6% 5% 5% 4% 4% 3% 3% 3% % % % % % % % % Admission Average NIHSS on admission: ; Median: 5 Median = Median = Median: mrs at Admit mrs mrs at at Admit Admit Ischemic SAH ICH Grade Grade Grade Grade Grade Grade Grade Grade 3 Grade 3 Grade 4 Grade 4 Grade Grade 53 Grade 5 Grade 4 Grade 5 % % 9% % 9% 8% 9% 8% 7% 8% 7% 7% 6% 6% 6% 5% 5% 5% 4% 4% 4% 3% 3% 3% % % % % % % % % % Discharge Average NIHSS on discharge: 7; Median: Median = Median = 3 Median: 3 mrs at Discharge mrs at Discharge 3-day Readmissions Stroke Patients 3/4 Avg 3 Jan 4 Feb Mar Apr May June July Aug Sept Oct Nov Dec Neurology 3.5 (9%) 4 (9%) 7 (%) 4 (5%) 5 (%) 5 (%) 5 (%) (4%) 3 (9%) (3%) (3%) (5%) (5%) Neurosurg.3 (7%) 3 (4%) 5 (38%) (9%) (%) (%) (%) (%) (%) (8%) (%) (5%) (%) Stroke Patients 4/5 Avg 4 Jan 5 Feb Mar Apr May June July Aug Sept Neurology 3.4 (8%) (3%) (%) (3%) 4 (7%) (%) (%) (%) (%) (4%) Neurosurg (6%) (%) (%) (5%) (%) (5%) (%) (%) (%) (%) 6

7 PSHMC 48 hour phone call to all stroke pts dc dto 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 dto home-clinical pharmacist Advantage found to waiting until after PCP visit 3-day, 9-day, -year stroke clinic visits 6% 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 apptsto 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 3-day stroke clinic up to % Automated phone reminder system Yikes looks one fix created another problem! 7

8 Stroke Clinic Experience Who Needs 3-day Clinic Follow-up? Probably not everyone Smoker Repeat Stroke Cryptogenic stroke Plan to restart meds (Ex.Anti coags) New A fib diagnosis New Diabetes Diagnosis Population Stats: 53% male; median age 68, BMI 3 8% mrs-, BI 9- Location at time of visit: 87% home, 6% ECF, 5% rehab Events/complications: 38% none, 5% depression, 9% falls Post Stroke Checklist results: 9% selected none, 56% yes to one item,9% yes to two items 69% Difficulty concentrating and remembering things 34% Feeling more anxious or depressed % New pain shoulder/arm, back Actions taken: 3% Provider referrals made 4% Therapies, Driver Eval, Botox ordered % Med changes Bundled Payment Experience 8

9 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 Successful Strategies for Post-acute Care Remote follow-up via telemedicine Collaboration with outside hospital telestrokepartner to have ptreturn there, eval dby 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 9

10 U of L CSC Resource Utilization for the Continuum of Care Stroke Service APRN Day of Discharge Home Documents Discharge mrs, BI, NIHSS Verify Home Phone Number and discharge address Verify pthas prescriptions for medications and any orders for outpatient rehab or diagnostic testing NeuroscienceOutpatient SSW Outpatient Stroke Coordinator Perform7 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 Needs assessment performed at 3 day f/u visit in stroke clinic as necessary Serves as a resource for healthcare system navigation throughout the continuum Schedules 3 day f/u appointment in stroke clinic Documents 3 day mrsin outpatient EHR and enter into GWTG-S at office visit or by phone call Facilitates all further care and diagnostics with provider Inpatient Stroke Coordinator Performs 9 day mrs by phone on all stroke patients and enter into GWTG-S Trends mrsbased on etiology of AIS, acute RX and discharge disposition 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) University of Louisville Comprehensive Stroke Center (ULSC) Lake Cumberland District Health

11 Stroke Patient Education & Navigation (SPEN) Methods Stroke patients transferred from TRH to ULSC discharged home LCDHD nurses made 3 home visits at weeks, 3 months, and 6 months to assess: biometrics Labs (AC, 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)

12 SPEN Study Outcomes & Results Outcomes Measured: Results: Conclusions: Primary Outcome: All cause readmission rate within 3 days and one year Secondary Outcomes: ) Medication Compliance ) Utilization of a community Resource 44 participants (October, 3- March 3, 5) 8 male, 6 female 3/44 completed all 3 visits /44 (5%) readmitted within 3 days ( TIA, Pneumonia) 36/44 (8%) compliant with medication /4 (8%) utilized a community resource /44 readmitted within year (3 vascular events MI, TIA, HTN) Cost = $36./patient 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

13 Questions? Kathy Morrison Alicia Richardson Kari Moore 3

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